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

Factors associated with attendance at screening for breast cancer: a systematic review and meta-analysis

OBJECTIVE

Attendance at population-based breast cancer (mammographic) screening varies. This comprehensive systematic review and meta-analysis assesses all identified patient-level factors associated with routine population breast screening attendance.

DESIGN

CINAHL, Cochrane Library, Embase, Medline, OVID, PsycINFO and Web of Science were searched for studies of any design, published January 1987-June 2019, and reporting attendance in relation to at least one patient-level factor.

DATA SYNTHESIS

Independent reviewers performed screening, data extraction and quality appraisal. OR and 95% CIs were calculated for attendance for each factor and random-effects meta-analysis was undertaken where possible.

RESULTS

Of 19 776 studies, 335 were assessed at full text and 66 studies (n=22 150 922) were included. Risk of bias was generally low. In meta-analysis, increased attendance was associated with higher socioeconomic status (SES) (n=11 studies; OR 1.45, 95% CI: 1.20 to 1.75); higher income (n=5 studies; OR 1.96, 95% CI: 1.68 to 2.29); home ownership (n=3 studies; OR 2.16, 95% CI: 2.08 to 2.23); being non-immigrant (n=7 studies; OR 2.23, 95% CI: 2.00 to 2.48); being married/cohabiting (n=7 studies; OR 1.86, 95% CI: 1.58 to 2.19) and medium (vs low) level of education (n=6 studies; OR 1.24, 95% CI: 1.09 to 1.41). Women with previous false-positive results were less likely to reattend (n=6 studies; OR 0.77, 95% CI: 0.68 to 0.88). There were no differences by age group or by rural versus urban residence.

CONCLUSIONS

Attendance was lower in women with lower SES, those who were immigrants, non-homeowners and those with previous false-positive results. Variations in service delivery, screening programmes and study populations may influence findings. Our findings are of univariable associations. Underlying causes of lower uptake such as practical, physical, psychological or financial barriers should be investigated.

TRIAL REGISTRATION NUMBER

CRD42016051597.

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.

The impact of compression force and pressure at prevalent screening on subsequent re-attendance in a national screening program

Adherence to screening may indirectly help assess whether a prior screening examination deters women from returning for a subsequent examination. We investigated whether compression force and pressure in mammography were associated with re-attendance among prevalently screened women in the organized breast cancer screening program in Norway. Data on compression force (kg) and pressure (kPa) from women's first screening examination in the program (prevalent screening) and subsequent re-attendance were available for 31,225 women aged 50-68, screened during 2007-2013. Crude re-attendance rates and log-binomial regression models estimating the prevalence ratio of re-attendance were used to identify the association between compression force or pressure and re-attendance two-years later. Age and year at prevalent screening, county of residence, screening result (negative or false positive), breast volume, and breast density were included in analyses. Overall, 27,197 (87.1%) women re-attended the program. Re-attendance was highest for women who received a compression force of 10.0-13.9 kg (87.5%) or pressure of 9.0-17.9 kPa (87.8%) and lowest for those who received a compression force of <10.0 kg (85.0%) or pressure of <9.0 kPa (84.7%). The adjusted prevalence of re-attendance was 3% lower for women who received low compression force (<10.0 kg) and 2% lower for women who received low compression pressure (<9.0 kPa) relative to the reference groups (10.0-13.9 kg and 9.0-17.9 kPa, respectively). Future research related to re-attendance should also include information about women's experience of pain, anxiety and stress, as well as image quality.

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.

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.

Compliance With Screening Mammography Guidelines After a False-Positive Mammogram

PURPOSE

To assess whether women with a false-positive mammogram who do return for screening are less likely to be compliant with screening mammography guidelines than are women with a negative mammogram.

METHODS

This institutional review board-approved, HIPAA-compliant retrospective cohort study includes women >40 years old who received 9,385 consecutive, nonbaseline screening mammograms between December 1, 2012 and December 31, 2013. Using linear regression, we evaluated differences in time between mammograms by prior recall status, after adjusting for location of current mammogram (outpatient office versus mobile unit) and age. Using Fisher's exact test, we evaluated the association between compliance with screening guidelines and the recall status on prior mammogram, and compared by location the proportions of noncompliant women who were recalled from prior mammogram.

RESULTS

Time between mammograms does not differ based on prior recall status (P = .83). There is no association between compliance with screening mammography guidelines and recall status on prior mammogram (ACR guidelines P = .398, United States Preventive Services Task Force guidelines P = .416). Noncompliant women recalled on prior mammogram are more likely to undergo mammography at the outpatient office rather than the mobile unit (ACR guidelines P = .0004, United States Preventive Services Task Force guidelines P = .0032).

CONCLUSIONS

A prior false-positive mammogram is not a significant deterrent to compliance with screening guidelines in those women who return for screening.

The Burden of False-Positive Results in Analog and Digital Screening Mammography: Experience of the Nova Scotia Breast Screening Program

Purpose

The Canadian Task Force on Preventive Health Care released recommendations for breast cancer screening, in part, based on harms associated with screening. The purpose of this study was to describe the rate of false-positive (FP) screening mammograms and to describe the extent of the investigations after an FP.

Methods

A cohort was identified that consisted of all screening mammograms performed through the Screening Program (2000-2011) with patients ages 40-69 years at screening. Rates of FP screening mammograms were calculated as well as rates of further investigations required, including additional imaging, needle core biopsy, and surgery. Analyses were stratified by 10-year age group, screening status (first vs rescreen), and technology.

Results

A total of 608,088 screening mammograms were included. The FP rate varied by age group, and decreased with increasing age (digital, 40-49 years old, FP = 8.0%; 50-59 years old, FP = 6.3%; 60-69 years old, FP = 4.6%). The FP rate also varied by screening status (digital, first screen, FP = 12.0%; rescreen, FP = 5.6%), and this difference was consistent across age groups. The need for further investigation varied by age group, with invasive procedures being more heavily used as women age (digital, rescreen group, surgery: 40-49 years old, 1.1%; 50-59 years old 1.6%, 60-69 years old, 1.8%).

Conclusions

Both the FP screening mammogram rate and the degree to which further investigation was required varied by age group and screening status. Reporting on these rates should form part of the evaluation of screening performance.

Re-attendance after false-positive screening mammography: a population-based study in the Netherlands

Background:

In the current study, mammography adherence of women who had experienced a false-positive referral is evaluated, with emphasis on the probability of receiving surveillance mammography outside the national screening programme.

Methods:

We included 424 703 consecutive screens and collected imaging, biopsy and surgery reports of 3463 women who experienced a false-positive referral. Adherence to screening, both in and outside the screening programme, was evaluated.

Results:

Two years after the false-positive referral, overall screening adherence was 94.6%, with 64.7% of women returning to the national screening programme, compared with 94.9% of women re-attending the screening programme after a negative screen (P<0.0001). Four years after the false-positive screen, the overall adherence had decreased to 85.2% (P<0.0001) with a similar proportion of the women re-attending the screening programme (64.4%) and a lower proportion (20.8%) having clinical surveillance mammography. Women who had experienced a false-positive screen at their first screening round were less likely to adhere to mammography than women with an abnormal finding at one of the following screening rounds (92.4% vs 95.5%, P<0.0001).

Conclusion:

Overall screening adherence after previous false-positive referral was comparable to the re-attendance rate of women with a negative screen at 2-year follow-up. Overall adherence decreased 4 years after previous false-positive referral from 94.6% to 85.2%, with a relatively high estimate of women who continue with clinical surveillance mammography (20.8%). Women with false-positive screens should be made aware of the importance to re-attend future screening rounds, as a way to improve the effectiveness of the screening programme.

The effect of false positive breast screening examinations on subsequent attendance: retrospective cohort study

Objectives

To investigate the effect of false positive breast screening examination results on subsequent attendance in the UK National Health Service Breast Screening Programme.

Methods

253,017 previously screened women who were invited for rescreening were studied. Attendance rates of women who had received a normal result at the last (index) screen were compared with those of women who had received a false positive result. The effects of age, type of index screening examination (prevalent or incident) and tissue sampling at assessment were investigated.

Results

Women who had a false positive prevalent index screening examination were significantly more likely to reattend than those who had a normal prevalent index screening examination (87.7% vs. 86.0%). There was no significant difference in reattendance rates between women who had a false positive incident index screening examination and those with a normal incident index screening examination. However, women who underwent needle sampling or open biopsy following false positive incident index screening examinations were 12% and 60% less likely to reattend, respectively, than women whose index screening examinations were normal ( p < 0.001), although there was variation between centres. Increasing age significantly reduced the likelihood of reattendance. The overall reattendance of women who had been screened only once was six percentage points lower than that of women who had been screened more than once.

Conclusions

The findings suggest that most women who undergo the breast screening assessment process retain confidence in breast screening. Needle sampling and open biopsy should be used judiciously in the assessment of screen-detected abnormalities in view of the reduced reattendance that results from their use after incident screening examinations.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

False-positive Mammographic Screening: Factors Influencing Re-attendance over a Decade of Screening

Introduction

International studies on the effect of false-positive mammographic screening results on subsequent re-attendance at screening are inconsistent.

Setting Breast

Check, the national breast screening programme for the Republic of Ireland, screens women two-yearly. Re-attendance for subsequent screening is approximately 90%.

Objectives and Methods

The aim of this research was to quantify the impact of false-positive mammographic screening results on subsequent re-attendance, using the BreastCheck clinical database with a decade of screening and to determine if age group, assessment procedure, initial or subsequent screening, location of appointment for next screening round and time from recall to non-malignant diagnosis predicted re-attendance.

Results

From programme commencement in 2000 to the end of 2007, 13,352 screening tests resulted in assessment; 11,765 participants were aged 50-62 years and of these 9746 received false-positive results (positive predictive value 17.2%). Following a false-positive recall to assessment, re-attendance at subsequent screening differed significantly by procedure type (open biopsy 80.3%; core biopsy only 90.2%; no tissue sampling 91.4%; P < 0.0001). Re-attendance differed significantly by timing of false-positive assessment in a woman's screening history (first versus subsequent screening, 89.5% versus 93.5%, P < 0.0001) and by location of next screening appointment (screening centre 89.8% versus mobile unit 91.3%, P < 0.01). The longer the period between recall to assessment and non-malignant diagnosis the less likely women were to re-attend. After logistic regression, first screening, older age, open surgical biopsy, re-invitation to screening centre and a longer period between recall and non-malignant diagnosis were significant negative predictors of re-attendance.

Conclusion

Since April 2008 BreastCheck has employed full field digital mammography throughout the programme, with a resulting increase in recalls; re-attendance will be closely monitored.

Influence of physician and patient characteristics on adherence to breast cancer screening recommendations

Identifying physician and patient characteristics is important in implementing effective, targeted strategies to improve breast cancer detection rates through increased screening recommendations and uptake. The purpose of this study was to determine whether Ontario physicians recommend breast screening using mammography every 2 years for women aged 50-69 as encouraged by the Ontario Breast Screening Program. This study also aimed to identify physician and patient characteristics that may influence adherence to these recommendations. The study design was a cross-sectional study. Using the Canadian Medical Directory-Ontario database, 3063 questionnaires were mailed to all active general and family practitioners. A response rate of 38% (N = 939) was achieved. Adherence to screening was defined as recommending screening to women aged 50-69 only, every 2 years as outlined by the Ontario Breast Screening Program. Bivariate analyses and unconditional logistic regression were used to assess physician adherence to screening guidelines. Only 38.9% of physicians followed recommended breast screening guidelines. After adjusting for physician sex and age, predictors of screening adherence include physicians working in academic or research centers (odds ratio 8.3, 95% confidence interval 1.7-39.7) and those reporting that over 31% of their patients to be of low-income (odds ratio 1.6, 95% confidence interval 1.1-2.4). Compared with physicians working in a rural/town setting (<10 000 people), those located in a large city (>100 000 people) were less likely to adhere to screening guidelines (odds ratio 0.5, 95% confidence interval 0.3-0.7). A low proportion of Ontario physicians adhere to recommended breast screening guidelines. Future research into effective strategies to increase adherence should take into account practice location, setting and patient characteristics.

Performance measures from 10 years of breast screening in the Ontario Breast Screening Program, 1990/91 to 2000

Performance measures for the Ontario Breast Screening Program (OBSP) by age group, time period and screening modality from 10 years of breast screening were evaluated. Data were available from routine information collected on 283,962 women aged 50 to 69 screened at 73 screening centres between 1 July 1990 and 31 December 2000. Although, initially, participation in the OBSP was low, this rate increased over time and the majority of women screened returned for subsequent screening. Abnormal call rates increased slightly over the time period, were higher in women aged 50 to 59, and for women with mammographic abnormalities. Detection rates of invasive cancer were higher and prognostic features of cancers were better for women age 60 to 69, and those referred by mammography. Along with the prognostic features of cancers, the benign to malignant surgical ratio and diagnostic interval improved over the time periods and for women aged 60 to 69. Greater proportions of women had shorter diagnostic intervals and were more likely to have a diagnosis of breast cancer after surgery if they were referred by both clinical breast examination and mammography. Although some enhancements of the programme are necessary, the OBSP met or exceeded Canadian targets for most performance measures.

Socioeconomic status & returning for a second screen in the Ontario breast screening program

In a retrospective cohort study involving 57902 women initially screened between January 1, 1995 and December 31 1997 by the Ontario Breast Screening Program (OBSP), we examined the relationship between geographically derived socioeconomic status (SES) and returning for a second screen. We controlled for age, rurality, preferred language, initial mammography results, previous mammography history, and referral by a health professional. Although SES was related to returning, rurality was an effect modifier of this relationship, a finding not previously reported. Compared to women in the highest ('richest') quintile, urban women in the first and second quintile were less likely to return; this relationship was not found in rural women. Low SES women, particularly in urban areas, should be specifically targeted to increase their likelihood of re-attendance for breast cancer screening within an organized program.