Monitoring women's experiences during three rounds of breast cancer screening: results from a longitudinal study

Women's Experiences with Digital Breast Tomosynthesis and Targeted Breast Ultrasound for Focal Breast Complaints: A Survey Study

Background: Owing to its high sensitivity, as concluded in the Breast UltraSound Trial (BUST), targeted ultrasound (US) now seems a promising accurate stand-alone modality for diagnostic evaluation of breast complaints. This approach implies omission of bilateral digital breast tomosynthesis (DBT) in women with clearly benign US findings. Within BUST, radiologists started with US followed by DBT. This side-study investigates women's experiences with DBT, their main motivation to undergo diagnostic imaging, and their view on US as a stand-alone modality. Methods: A subset of BUST participants completed a questionnaire on their DBT experiences, reason for undergoing diagnostic assessment, and view on US-only diagnostics. Responses were analyzed with descriptive statistics and logistic regression analyses. Results: In total, 778 of 838 women (response rate 92.8%) were included (M = 47, SD = 11.16). Of them, 16.8% reported no burden of DBT, 33.5% slight burden, 31.0% moderate, and 12.7% severe burden. Furthermore, 13% reported no pain, 35.3% slight pain, 33.2% moderate, and 11.3% severe pain. Moreover, 88.3% indicated that the most important reason for breast assessment was explanation of their complaint and to rule out breast cancer, whereas 3.2% wanted to "check" both breasts. And 82.4% reported satisfaction with US only in case of a nonmalignancy. Conclusions: Our study shows that most women in the diagnostic setting experience at least slight-to-moderate DBT-related burden and pain, and that explanation for their symptoms is their main interest. Also, the majority report satisfaction with US only in case of nonmalignant findings. However, exploration of women's perspectives outside this study is needed as our participants all underwent both examinations.

Assessing the impact of binaural and non-binaural auditory beat intervention to pain and compression in mammography

INTRODUCTION

Pain and discomfort has a negative impact on a patient's overall experience and may impact on subsequent re-attendance to mammography. Pain during mammography remains a significant issue. Assessment of interventions to reduce levels of pain associated with mammography are essential to increase attendance to breast services and improve user experience.

METHODS

Participants (n = 60) were invited to take part in the study at one hospital Trust within the UK. Postal invitations were sent 2 weeks prior to appointment to patients older than 40 years with previous mammography attendance at the same Trust to allow for comparison of previous and current pain scores/compression values. Patients were randomised into 3 groups: Binaural music (BM), non-binaural music (NBM) and standard care (C). A numerical rating scale (NRS) was used to rate pain.

RESULTS

Patient tolerance is increased by the application of both the non-binaural and binaural music. Binaural music was most effective in improving patient tolerance (p = 0.02). When applied compression increased some patients recorded less pain, which may have implications to image quality and radiation dose for patients. Binaural music reduces the perception of mammographic pain within this data set.

CONCLUSION

5 min exposure to binaural music improves patient experience and tolerance for mammography which could be utilised to improve attendance rates in screening and symptomatic services.

IMPLICATIONS FOR PRACTICE

There is an indication for further research looking at application prior and during interventional biopsies. Music intervention can be offered to patients in the severe pain category who refuse mammography. It is acknowledged from these findings that the introduction of BM and NBM prior to mammography would be a low risk, cost effective intervention within the hospital setting.

The Effect of Targeted Ultrasound as Primary Imaging Modality on Quality of Life in Women with Focal Breast Complaints: A Comparative Cohort Study

Background: The high diagnostic performance of modern breast ultrasound (US) opens the possibility to shift toward targeted US as initial imaging test in women with breast complaints. This comparative cohort study investigates the effects of starting with US followed by digital breast tomosynthesis (DBT), as practiced in the breast ultrasound study (BUST), on women's health-related quality of life (QoL). Methods: Fifty BUST participants and 50 "controls" who underwent DBT and US in regular order filled out the EQ-5D-3L three times during their visit: BUST participants before US (T1), after US (T2), and after DBT (T3) and non-BUST participants before DBT (T1), after DBT (T2), and after US (T3). Changes in QoL from baseline to T2 and T3 were assessed using generalized least squares, also taking into account the effects of biopsy, age, and complaint type. Results: Participants' mean age was 50.6 years (BUST: SD = 12.1, controls: SD = 11.5). At T2 the overall QoL was higher [t(102.9) = 2.4, p = 0.017] and anxiety levels were lower [t(98.7) = -2.4, p = 0.020] in BUST participants compared with controls. However, from T2 to T3 these effects equalize, resulting in similar performances in QoL and anxiety at T3, respectively [t(97.6) = -2.3, p = 0.023] and [t(97.2) = 3.1, p = 0.002]. Compared with BUST participants, controls show a clear decrease in pain after US [t(106.5) = -2.8, p = 0.006]. Women undergoing biopsy had lower QoL [t(167.1) = -2.4, p = 0.017] and pain [t(154.1) = -2.1, p = 0.038], and more anxiety [t(187.4) = 4.3, p = 0.000]. Conclusions: The results suggest that changing the radiological order by starting with US has a short-term positive effect on overall QoL, anxiety, and DBT pain experience in symptomatic women. Owing to its negative impact, biopsies should be performed cautiously. In conclusion, the moment of reassurance for women advances by reversing the radiological order according to the BUST, showing the high importance of human interaction in diagnostic care in addition to the clinical performance of imaging modalities.

Systematic reviews as a "lens of evidence": Determinants of participation in breast cancer screening

OBJECTIVE

To assess the determinants of the participation rate in breast cancer screening programs by conducting a systematic review of reviews.

METHODS

We conducted a systematic search in PubMed via Medline, Scopus, Embase, and Cochrane identifying the literature up to April 2019. Out of 2258 revealed unique abstracts, we included 31 reviews, from which 25 were considered as systematic. We applied the Walsh & McPhee Systems Model of Clinical Preventive Care to systematize the determinants of screening participation.

RESULTS

The reviews, mainly in high-income settings, reported a wide range for breast cancer screening participation rate: 16-90%. The determinants of breast cancer screening participation were simple low-cost interventions such as invitation letters, basic information on screening, multiple reminders, fixed appointments, prompts from healthcare professionals, and healthcare organizational factors (e.g. close proximity to screening facility). More complex interventions (such as face-to-face counselling or home visits), mass media or improved access to transport should not be encouraged by policy makers unless other information appears. The repeated participation in mammography screening was consistently high, above 62%. Previous positive experience with screening influenced the repeated participation in screening programs. The reviews were inconsistent in the use of terminology related to breast cancer screening participation, which may have contributed to the heterogeneity in the reported outcomes.

CONCLUSIONS

This study shows that consistent findings of systematic reviews bring more certainty into the conclusions on the effects of simple invitation techniques, fixed appointments and prompts, as well as healthcare organizational factors on promoting participation rate in screening mammography.

Scanxiety: a scoping review about scan-associated anxiety

OBJECTIVES

To identify available literature on prevalence, severity and contributing factors of scan-associated anxiety ('scanxiety') and interventions to reduce it.

DESIGN

Systematic scoping review.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Scopus, EBSCO CINAHL and PubMed up to July 2020.

STUDY SELECTION

Eligible studies recruited people having cancer-related non-invasive scans (including screening) and contained a quantitative assessment of scanxiety.

DATA EXTRACTION

Demographics and scanxiety outcomes were recorded, and data were summarised by descriptive statistics.

RESULTS

Of 26 693 citations, 57 studies were included across a range of scan types (mammogram: 26/57, 46%; positron-emission tomography: 14/57, 25%; CT: 14/57, 25%) and designs (observation: 47/57, 82%; intervention: 10/57, 18%). Eighty-one measurement tools were used to quantify prevalence and/or severity of scanxiety, including purpose-designed Likert scales (17/81, 21%); the State Trait Anxiety Inventory (14/81, 17%) and the Hospital Anxiety and Depression Scale (9/81, 11%). Scanxiety prevalence ranged from 0% to 64% (above prespecified thresholds) or from 13% to 83% ('any' anxiety, if no threshold). Mean severity scores appeared low in almost all measures that quantitatively measured scanxiety (54/62, 87%), regardless of whether anxiety thresholds were prespecified. Moderate to severe scanxiety occurred in 4%-28% of people in studies using descriptive measures. Nine of 20 studies assessing scanxiety prescan and postscan reported significant postscan reduction in scanxiety. Lower education, smoking, higher levels of pain, higher perceived risk of cancer and diagnostic scans (vs screening scans) consistently correlated with higher scanxiety severity but not age, gender, ethnicity or marital status. Interventions included relaxation, distraction, education and psychological support. Six of 10 interventions showed a reduction in scanxiety.

CONCLUSIONS

Prevalence and severity of scanxiety varied widely likely due to heterogeneous methods of measurement. A uniform approach to evaluating scanxiety will improve understanding of the phenomenon and help guide interventions.

Screening Mammography Among Older Women: A Review of United States Guidelines and Potential Harms

In the United States, older women (aged ≥65 years) continue to receive routine screening mammography surveillance, despite limited evidence supporting the benefits to this subpopulation. This article reviews screening mammography guidelines and the potential harms of such screening for older women in the United States. Published guidelines and recommendations on screening mammography for older women from professional medical societies and organizations in the United States were reviewed from the mid-20th century to present. Observational data were then synthesized to present the documented harms from screening mammography among older women. In 1976, the American Cancer Society recommended to screen all women aged ≥40 years with no upper age limit. With time, other major U.S. medical societies adopted their own screening guidelines without a consensus on age of screening cessation. A population-wide screening effort has largely continued without an upper age limit and with it, a growing body of literature on the harms of screening older women. Reported harms from screening mammography procedures have included physical pain, psychological distress, excessive use of health services from overdiagnoses/false positives, and undue financial expenses. These costs are particularly pronounced among special populations with limited life expectancies such as those of very advanced age ≥80 years, long-term nursing home residents, and the cognitively impaired. When potential harms, remaining life years, and the viability of available treatments are considered, the burdens of screening mammography often outweigh the benefits for older women. For some cases, an individualized approach to recommendations would be appropriate. National guidelines should be updated to provide clear guidance for screening women of advanced age, especially those in special populations with limited life expectancies.

Double-blind placebo-controlled randomized clinical trial on the use of paracetamol for performing mammography

BACKGROUND

This study was conducted within the Goias Mastology Research Network. To verify the possibility of diminishing pain, and discomfort during the mammography using analgesic administration.

METHODS

Randomized, double-blinded, placebo controlled trial, testing paracetamol to diminish the pain, and discomfort during mammography. Three hundred patients who came for screening mammography were randomized for this study. A questionnaire with 2 parts was used: the first had questions that concerned the patient identification, and factors related to the pain during mammography; and the second asked about the scale of discomfort (no discomfort; uncomfortable; very uncomfortable; intolerable), and the pain (analogical linear scale) during the mammography. Each patient received 1000 mg of paracetamol, or placebo. Afterwards each patient filled out the second part of the questionnaire. Six patients were excluded from the analysis; this resulted in 149 in the paracetamol group, and 145 in the placebo group.

RESULTS

The 2 groups were homogenous concerning the mean of the ages, weight, height, and breast size. The mean of the pain was 3.5 in the paracetamol, and 2.8 in the placebo group (P = .12). There were fewer women experiencing mild pain in the paracetamol group when compared with those in placebo group (relative risk [RR] 0.76, confidence interval [CI] 95% 0.52-0.98). There was no significant difference between the 2 groups, according to the degrees of discomfort (P =  .69).

CONCLUSION

The use of paracetamol can reduces the mild pain for women undergoing mammography.

The impact of false positive breast cancer screening mammograms on screening retention: A retrospective population cohort study in Alberta, Canada

OBJECTIVES

The impact of false positives on breast cancer screening retention is inconsistent across international studies. We investigate factors associated with screening retention, including false positive screening results, invasiveness of diagnostic procedures, and geographic variation in Alberta, Canada.

METHODS

A total of 213 867 women aged 50-67 years who had an index screen mammogram between July 2006 and June 2008 were evaluated at 30 months post index screen to determine the screening retention rate. The association of screening retention with invasiveness of the diagnostic procedure, time to diagnostic resolution, and region of residence were investigated using multivariable log binomial regression, adjusting for women's age.

RESULTS

Women with false positive screening results were less likely to return for their next recommended screening than those with a true negative result (62.0% vs. 68.7%). Compared to women with normal screening results, the adjusted risk ratios of fail-to-rescreen for women with imaging-only follow-up, needle sampling, and open biopsy were 1.08 (95% CI: 1.05-1.12), 1.72 (95% CI: 1.44-2.07) and 2.29 (95% CI: 2.09-2.50) respectively. Screening retention rates were slightly higher for rural residents than urban residents. Time to diagnostic resolution was not associated with screening retention. Screening retention peaked at one year from the index date of the previous screening.

CONCLUSION

Higher awareness of the strong negative impact that biopsies in the case of a false positive screening have on screening retention is needed. Such awareness can inform intervention strategies to mitigate the impact and improve screening retention rate.

Mammography: an update of the EUSOBI recommendations on information for women

Abstract

This article summarises the information to be offered to women about mammography. After a delineation of the aim of early diagnosis of breast cancer, the difference between screening mammography and diagnostic mammography is explained. The need to bring images and reports from the previous mammogram (and from other recent breast imaging examinations) is highlighted. Mammography technique and procedure are described with particular attention to discomfort and pain experienced by a small number of women who undergo the test. Information is given on the recall during a screening programme and on the request for further work-up after a diagnostic mammography. The logic of the mammography report and of classification systems such as R1-R5 and BI-RADS is illustrated, and brief but clear information is given about the diagnostic performance of the test, with particular reference to interval cancers, i.e., those cancers that are missed at screening mammography. Moreover, the breast cancer risk due to radiation exposure from mammography is compared to the reduction in mortality obtained with the test, and the concept of overdiagnosis is presented with a reliable estimation of its extent. Information about new mammographic technologies (tomosynthesis and contrast-enhanced spectral mammography) is also given. Finally, frequently asked questions are answered.

Key Points

• Direct digital mammography should be preferred to film-screen or phosphor plates.

• Screening (in asymptomatic women) should be distinguished from diagnosis (in symptomatic women).

• A breast symptom has to be considered even after a negative mammogram.

• Digital breast tomosynthesis increases cancer detection and decreases the recall rate.

• Contrast-enhanced spectral mammography can help in cancer detection and lesion characterisation.

What Do Patients Tweet About Their Mammography Experience?

RATIONALE AND OBJECTIVE

The purpose of this study was to evaluate themes related to patients' experience in undergoing mammography, as expressed on Twitter.

METHODS

A total of 464 tweets from July to December 2015 containing the hashtag #mammogram and relating to a patient's experience in undergoing mammography were reviewed.

RESULTS

Of the tweets, 45.5% occurred before the mammogram compared to 49.6% that occurred afterward (remainder of tweets indeterminate). However, in patients undergoing their first mammogram, 32.8% occurred before the examination, whereas in those undergoing follow-up mammogram, 53.0% occurred before the examination. Identified themes included breast compression (24.4%), advising other patients to undergo screening (23.9%), recognition of the health importance of the examination (18.8%), the act of waiting (10.1%), relief regarding results (9.7%), reflection that the examination was not that bad (9.1%), generalized apprehension regarding the examination (8.2%), interactions with staff (8.0%), the gown (5.0%), examination costs or access (3.4%), offering or reaching out for online support from other patients (3.2%), perception of screening as a sign of aging (2.4%), and the waiting room or waiting room amenities (1.3%). Of the tweets, 31.9% contained humor, of which 56.1% related to compression. Themes that were more common in patients undergoing their first, rather than follow-up, mammogram included breast compression (16.4% vs 9.1%, respectively) and that the test was not that bad (26.2% vs 7.6%, respectively).

CONCLUSION

Online social media provides a platform for women to share their experiences and reactions in undergoing mammography, including humor, positive reflections, and encouragement of others to undergo the examination. Social media thus warrants further evaluation as a potential tool to help foster greater adherence to screening guidelines.

Integrating Customer Intimacy Into Radiology to Improve the Patient Perspective: The Case of Breast Cancer Screening

OBJECTIVE

The customer intimacy business model has emerged as a key operational approach for health care organizations as they move toward patient-centered care. The question arises how the customer intimacy approach can be implemented in the clinical setting and whether it can help practitioners address problems and improve quality of care.

CONCLUSION

Breast cancer screening and its emphasis on the patient perspective provides an interesting case study for understanding how the customer intimacy approach can be integrated into radiologic practice to improve the patient experience.

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.

Pain-preventing strategies in mammography: an observational study of simultaneously recorded pain and breast mechanics throughout the entire breast compression cycle

Background

Many women consider mammography painful. Existing studies on pain-preventing strategies only mention pain scores reported before and after breast compression. Studying the pain dynamics during the entire compression cycle may provide new insights for effective pain-preventing strategies.

Methods

This observational study included 117 women who consented to use a custom turning knob to indicate their pain experience during standard mammographic breast compressions in the Academic Medical Center in Amsterdam, The Netherlands. The breast thickness, compression force, contact area, contact pressure and pain experience were recorded continuously. Breast volume was calculated retrospectively from the mammograms. We visualized the progression of pain in relation to breast mechanics for five groups of breast volumes and we performed multivariable regressions to identify factors that significantly predict pain experience.

Results

Breast compressions consisted of a deformation phase for flattening, and a clamping phase for immobilization. The clamping phase lasted 12.8 ± 3.6 seconds (average ± standard deviation), 1.7 times longer than the 7.5 ± 2.6 seconds deformation phase. During the clamping phase, the average pain score increased from 4.75 to 5.88 (+24%) on a 0 – 10 Numerical Rating Scale (NRS), and the proportion of women who reached severe pain (NRS ≥ 7) increased from 23% to 50% (more than doubled). Moderate pain (NRS ≥ 4) was reported up to four days after the mammogram. Multivariable analysis showed that pain recollection of the previous mammogram and breast pain before the compression, are significant predictors for pain. Women with smallest breasts experienced most pain: They received highest contact pressures (force divided by contact area) and the pressure increased at the highest rate.

Conclusion

We suggest further research on two pain-preventing strategies: 1) using a personalized compression protocol by applying to all breasts the same target pressure at the same, slow rate, and 2) shortening the phase during which the breast is clamped.

Comparison of a flexible versus a rigid breast compression paddle: pain experience, projected breast area, radiation dose and technical image quality

PURPOSE

To compare pain, projected breast area, radiation dose and image quality between flexible (FP) and rigid (RP) breast compression paddles.

METHODS

The study was conducted in a Dutch mammographic screening unit (288 women). To compare both paddles one additional image with RP was made, consisting of either a mediolateral-oblique (MLO) or craniocaudal-view (CC). Pain experience was scored using the Numeric Rating Scale (NRS). Projected breast area was estimated using computer software. Radiation dose was estimated using the model by Dance. Image quality was reviewed by three radiologists and three radiographers.

RESULTS

There was no difference in pain experience between both paddles (mean difference NRS: 0.08 ± 0.08, p = 0.32). Mean radiation dose was 4.5 % lower with FP (0.09 ± 0.01 p = 0.00). On MLO-images, the projected breast area was 0.79 % larger with FP. Paired evaluation of image quality indicated that FP removed fibroglandular tissue from the image area and reduced contrast in the clinically relevant retroglandular area at chest wall side.

CONCLUSIONS

Although FP performed slightly better in the projected breast area, it moved breast tissue from the image area at chest wall side. RP showed better contrast, especially in the retroglandular area. We therefore recommend the use of RP for standard MLO and CC views.

Development and validation of an instrument assessing women's satisfaction with screening mammography in an organized breast cancer screening program

Background

The assessment of the quality of mammography services delivered in organized breast cancer screening programs should include measures centered on women’s perceptions. The objective of this study was to develop and validate an instrument in French designed to evaluate the satisfaction of women having a screening mammography.

Methods

An instrument evaluating women’s satisfaction with mammography services was developed using published research, the perceptions of screened women, the expertise of health professionals and a pilot study. Between November 9 and 21, 2011, the questionnaire was sent to 1500 consecutive women having had a screening mammography in eight radiologic facilities designated by the Québec Breast Cancer Screening Program, in Quebec City, Canada. Construct validity, convergent and discriminant validity, reliability and sensitivity of the instrument were examined.

Results

A total of 819 women (55%) participated in the validation study. The factor analysis retained four satisfaction dimensions: satisfaction with 1) the technician’s skills (four items), 2) the physical environment (four items), 3) the staff’s communication skills (three items) and 4) the information given by the program (3 items). The multitrait-scaling analysis showed good convergent and discriminant validity: scaling success was 100% for all subscales. All subscales had good internal consistency (Cronbach’s alphas ≥ 0.86). The satisfaction scores were able to identify groups of women with lower levels of satisfaction, such as younger women or women with pain during breast compression.

Conclusion

This brief satisfaction instrument, developed in French, showed good psychometric properties to evaluate satisfaction in women receiving mammographic services in an organized breast cancer screening program.

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

AIMS

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Mammography: EUSOBI recommendations for women's information

This paper summarises the basic information to be offered to women who undergo mammography. After a delineation of the general aim of early diagnosis of breast cancer, the main difference between screening mammography and diagnostic mammography is explained. The best time for scheduling mammography in fertile women is defined. The need to bring images and reports from the previous mammogram (and from other recent breast imaging examinations) is highlighted. The technique and procedure of mammography are briefly described with particular attention to discomfort and pain experienced by a fraction of women who undergo the test. Information is given on the recall during a screening program and on the request for further work-up after a diagnostic mammography. The logic of the diagnostic mammography report and of classification systems such as BI-RADS and R1-R5 is illustrated, and brief but clear information is given about the diagnostic performance of the test, with particular reference to interval cancers. Moreover, the breast cancer risk due to radiation exposure from mammography is compared to the reduction in mortality obtained with the test, and the concept of overdiagnosis is presented. Finally, five frequently asked questions are answered.

Satisfaction with initial screen and compliance with biennial breast screening at centers with and without nurses

BACKGROUND

A woman's experience during her initial breast screen can influence her participation in subsequent screening.

OBJECTIVE

The purpose of this study was to determine the association between a woman's satisfaction with her initial screening experience and compliance to biennial screening at centers with and without nurses.

METHODS

A stratified random sample of compliers and noncompliers to biennial screening was selected from a cohort of 16 858 eligible women aged 50 to 65 years attending centers with and without nurses for their initial screen at the Ontario Breast Screening Program in 2002. Of these eligible women, 3387 were sent questionnaires, 2640 (77.9%) were contacted, and 1901 (72.0%) were interviewed. The association between satisfaction with initial screen and compliance was estimated separately for centers with and without nurses using logistic regression.

RESULTS

Women attending centers with nurses were significantly less likely to comply with their next screen after their clinical breast examination if they were not completely satisfied with the service they received (odds ratio, 0.21; 95% confidence interval, 0.08-0.57) or agreed that the clinical breast examination caused discomfort to their breasts (odds ratio, 0.65; 95% confidence interval, 0.45-0.94). In addition, women attending centers with or without nurses were significantly less likely to comply if they did not understand why they needed to return for screening.

CONCLUSIONS

: Nurses at screening centers have an opportunity to significantly impact a woman's compliance to biennial breast screening by providing a positive initial screening experience.

IMPLICATIONS FOR PRACTICE

Emphasis should be placed on improving a woman's overall satisfaction with her initial screening experience.

Client satisfaction in a breast and cervical cancer early detection program: the influence of ethnicity and language, health, resources, and barriers

OBJECTIVES

Satisfaction is a critical outcome for the healthcare system and an important influence on subsequent interactions with that system, yet findings have been inconsistent. This paper examined satisfaction as a multidimensional construct and focused on the interrelated influences of ethnicity and language, the potential confounding effects of economic resources and health status, and the possible role of perceived barriers to service delivery.

METHODS

The study was based on a phone survey conducted in 2005 of a stratified random sample of 207 Massachusetts patients in the National Breast and Cervical Cancer Early Detection Program, which used case managers to increase the rates of diagnostic testing among uninsured women at risk of breast or cervical cancer. Ethnicity, primary language, economic resources, and health status were each related to particular dimensions of patient satisfaction, but mostly independent of perceived barriers to program participation.

RESULTS

The findings indicated that adequate evaluation of public health programs must conceptualize and measure satisfaction as multidimensional and supported the prediction of "segmented assimilation theory" that satisfaction can decline with time in the U.S.

Intentions to maintain adherence to mammography

OBJECTIVE

Recent attention has focused on moving women from having initial mammograms to maintaining adherence to regular mammography schedules. We examined behavioral intentions to maintain mammography adherence, which include the likelihood of performing a behavior, and implementation intentions, specific action plans to obtain mammograms. Potential predictors were Theory of Planned Behavior constructs, previous barriers, previous mammography maintenance, and age.

METHODS

Respondents were 2062 currently adherent women due for their next mammograms in 3-4 months according to American Cancer Society recommendations for annual screening. Statistical models were used to examine predictors of behavioral and two implementation intentions, including having thought about where women would get their next mammograms and having thought about making appointments.

RESULTS

With the exception of pros, cons, and subjective norms, all variables predicted behavioral intentions (p <or= 0.05). Stronger perceived control, previous mammography maintenance, and one barrier (vs. none) predicted being more likely to have thought about where to get their next mammograms. Previous maintenance and no barriers (vs. two) predicted being more likely to have thought about making appointments.

CONCLUSIONS

Our findings suggest that among women currently adherent to mammography, volitional factors, such as barriers, may be better predictors of implementation intentions than motivational factors, such as attitudes. Implementation variables may be useful in understanding how women move from intentions to action. Future research should examine how such factors relate to mammography maintenance behaviors and can be integrated into behavior change interventions.

Comparison of satisfaction with cancer screening at mobile van and static sites: National Cancer Screening Program in Korea

OBJECTIVES

Our objectives were to evaluate participant satisfaction in the National Cancer Screening Program (NCSP) and to examine differences in satisfaction between mobile vans and static sites.

METHODS

A total of 243 967 participants who were screened by NCSP between January and May 2007 were eligible for the study. Of these, 3416 samples were randomly chosen and stratified by the type of cancer screened and screening unit. A telephone survey was conducted in July 2007, and 1672 participants (48.9%) were responded. The questionnaire included participant satisfaction with screening, screening service use and demographic data. Five multiple regression models were used to determine the relation between screening location (mobile van or static site) and each of five satisfaction measures (information transfer, staff interpersonal skills, privacy protection, physical surroundings and general satisfaction).

RESULTS

Of the participants, 764 (45.7%) were screened at a mobile van and 908 (54.3%) at a static site. Relatively high scores were reported for all satisfaction measures, but satisfaction with screening at a mobile van was lower than that at a static site. Even after adjusting for potential confounders, screening at a mobile van was significantly associated with lower satisfaction for information transfer (P = 0.005), staff interpersonal skills (P = 0.025), privacy protection (P = 0.019), physical surroundings (P < 0.001) and general satisfaction (P < 0.001).

CONCLUSIONS

Improving the satisfaction with and quality of mobile screening services is important to increase compliance and achieve the aims of the NCSP. Therefore, further efforts such as quality assurance or continuous monitoring are required.

"It's much easier than going to the dentist": high levels of satisfaction in a mammography screening program

OBJECTIVES

To develop a suitable instrument for measuring client satisfaction in the BreastScreen New South Wales (NSW) program and to use the instrument to measure client satisfaction.

METHOD

The survey was designed and administered to 2,091 women who attended mammography screening in the BreastScreen NSW program during 2001 (85% response rate). The survey evaluated experiences of making appointments, the screening environment, the screening procedure, and the receipt of results. Socio-demographic differentials in client satisfaction were examined using logistic regression models.

RESULTS

The majority of women were highly satisfied with their experience, with transport/parking, breast discomfort and time to results causing the most dissatisfaction (8-9%). The main source of dissatisfaction was during the appointment and related to discomfort during the mammogram (9%) and breast problems following the mammogram (9%). Predictors of dissatisfaction with screening (p<0.05) included high education level (OR=1.4), non-Australian born (OR=1.4), and aged 40-49 years (OR=1.6).

CONCLUSIONS

Although overall satisfaction was high, the survey indicated service functions where improvements could be made.

IMPLICATIONS

This research has developed an appropriate tool for assessing and monitoring client satisfaction with breast screening services.

The psychological impact of mammographic screening. A systematic review

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

Pattern of participation in a cohort aged 50-60 years at first invitation to the service-screening programme with mammography in Stockholm county, Sweden

BACKGROUND

Mammography screening can only be effective if a high proportion of the invited women attend. The aim of the present study was to search for patterns of participation in women who were invited to five consecutive rounds in a large screening programme.

METHOD

Stockholm service-screening programme started 1989 and invites women between 50 and 69 years of age to mammography with 2 years interval. 64,852 women were eligible for an invitation to all five rounds during a 10-year period and were included in the study.

RESULTS

More than 50% attended at all five rounds, and more than 70% at least four rounds. Only 8.5% were permanent non-participants. Women who attended at the first invitation round were more likely to attend also at subsequent rounds.

CONCLUSIONS

It is possible to reach a high participation also in a large urban screening programme, but it seems that the invitation and examination at first round are most important in order to get a high compliance. Women who come at first round are more likely to come back for routine screening at a majority of subsequent rounds.

Relaxation techniques for reducing pain and anxiety during screening mammography

OBJECTIVE

The purpose of this study was to determine whether listening to a relaxation audiotape before and during mammography decreases subjective reports of pain and anxiety.

CONCLUSION

Listening to a relaxation or music audiotape before and during mammography does not reduce subjective reports of anxiety or pain. Women undergoing screening mammography report minimal levels of distress.

Coping Style and Women's Participation in Breast and Gynecological Screening

The purpose of this project was to determine the role of coping style in women's practice of breast and gynecological screening behaviors. Women were classified into one of four coping groups based on measures of vigilance and screening distress. Data were analyzed from a subset of 85 U.S. women who participated in a larger longitudinal study designed to examine self-reported screening participation. Results indicate frequency of screening participation and importance of obtaining immediate mammography feedback differed across coping style groups. Women characterized as high in vigilance and screening distress were most at risk for nonparticipation in screening.

The psychological impact of mammographic screening on women with a family history of breast cancer—a systematic review

This systematic review aims to assess the psychological impact of mammographic screening on women with a family history of breast cancer. Women with a family history, and hence increased risk, of breast cancer are known to experience higher levels of anxiety about cancer. They are also often offered screening from an earlier age. The psychological consequences of screening are therefore of particular importance for this group of women. A comprehensive search of 4 electronic databases was conducted from 1982 to 2003, combining sets of terms relating to (1) breast screening or mammography (breast screen*; mammogra*), (2) psychological impact (adverse effects; anxi*; distress; nervous; psych*, psychological consequences; stress; worry) and (3) family history. Reference lists from relevant papers were examined for additional papers. The review identified seven papers from four countries. Overall, the findings indicate that, similar to women in the general population, most women with a family history do not appear to experience high levels of anxiety associated with mammographic screening. Although women who are recalled for further tests do experience increased anxiety the levels appear to be no greater than for women without a family history. We conclude that further research on this topic is required--this should include studies designed specifically to consider both the negative and positive impact of mammographic screening on women with a family history, using validated measures of anxiety and worry in combination with qualitative research.