Systematic review of the psychological consequences of false-positive screening mammograms

- Background In the UK, women aged 50–73 years are invited for screening by mammography every 3 years. In 2009–10, more than 2.24 million women in this age group in England were invited to take part in the programme, of whom 73% attended a screening clinic. Of these, 64,104 women were recalled for assessment. Of those recalled, 81% did not have breast cancer; these women are described as having a false-positive mammogram. - Objective The aim of this systematic review was to identify the psychological impact on women of false-positive screening mammograms and any evidence for the effectiveness of interventions designed to reduce this impact. We were also looking for evidence of effects in subgroups of women. - Data sources MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register for Controlled Trials, Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination (CRD) Database of Abstracts of Reviews of Effects, CRD Health Technology Assessment (HTA), Cochrane Methodology, Web of Science, Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index-Science, Conference Proceeding Citation Index-Social Science and Humanities, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, the International Bibliography of the Social Sciences, the British Library's Electronic Table of Contents and others. Initial searches were carried out between 8 October 2010 and 25 January 2011. Update searches were carried out on 26 October 2011 and 23 March 2012. - Review methods Based on the inclusion criteria, titles and abstracts were screened independently by two reviewers. Retrieved papers were reviewed and selected using the same independent process. Data were extracted by one reviewer and checked by another. Each included study was assessed for risk of bias. - Results Eleven studies were found from 4423 titles and abstracts. Studies that used disease-specific measures found a negative psychological impact lasting up to 3 years. Distress increased with the level of invasiveness of the assessment procedure. Studies using instruments designed to detect clinical levels of morbidity did not find this effect. Women with false-positive mammograms were less likely to return for the next round of screening [relative risk (RR) 0.97; 95% confidence interval (CI) 0.96 to 0.98] than those with normal mammograms, were more likely to have interval cancer [odds ratio (OR) 3.19 (95% CI 2.34 to 4.35)] and were more likely to have cancer detected at the next screening round [OR 2.15 (95% CI 1.55 to 2.98)]. - Limitations This study was limited to UK research and by the robustness of the included studies, which frequently failed to report quality indicators, for example failure to consider the risk of bias or confounding, or failure to report participants' demographic characteristics. - Conclusions We conclude that the experience of having a false-positive screening mammogram can cause breast cancer-specific psychological distress that may endure for up to 3 years, and reduce the likelihood that women will return for their next round of mammography screening. These results should be treated cautiously owing to inherent weakness of observational designs and weaknesses in reporting. Future research should include a qualitative interview study and observational studies that compare generic and disease-specific measures, collect demographic data and include women from different social and ethnic groups.

Advanced breast cancer incidence following population-based mammographic screening

Background: Breast cancer mortality is declining in many Western countries. If mammography screening contributed to decreases in mortality, then decreases in advanced breast cancer incidence should also be noticeable.
Patients and methods: We assessed incidence trends of advanced breast cancer in areas where mammography screening is practiced for at least 7 years with 60% minimum participation and where population-based registration of advanced breast cancer existed. Through a systematic Medline search, we identified relevant published data for Australia, Italy, Norway, Switzerland, The Netherlands, UK and the USA. Data from cancer registries in Northern Ireland, Scotland, the USA (Surveillance, Epidemiology and End Results (SEER), and Connecticut), and Tasmania (Australia) were available for the study. Criterion for advanced cancer was the tumour size, and if not available, spread to regional/distant sites.
Results: Age-adjusted annual percent changes (APCs) were stable or increasing in ten areas (APCs of -0.5% to 1.7%). In four areas (Firenze, the Netherlands, SEER and Connecticut) there were transient downward trends followed by increases back to pre-screening rates.
Conclusions: In areas with widespread sustained mammographic screening, trends in advanced breast cancer incidence do not support a substantial role for screening in the decrease in mortality.

Breast cancer mortality in neighbouring European countries with different level of breast screening but similar access to treatment: An analysis of WHO mortality database

Objective: To compare trends in breast cancer mortality within three pairs of neighbouring European countries in relation to implementation of screening. Design: Retrospective trend analysis.
Setting: Three country pairs (Northern Ireland (United Kingdom) v Republic of Ireland, the Netherlands v Belgium and Flanders (Belgian region south of the Netherlands), and Sweden v Norway).
Data sources: WHO mortality database on cause of death and data sources on mammography screening, cancer treatment, and risk factors for breast cancer mortality.
Main outcome measures: Changes in breast cancer mortality calculated from linear regressions of log transformed, age adjusted death rates. Joinpoint analysis was used to identify the year when trends in mortality for all ages began to change.
Results: From 1989 to 2006, deaths from breast cancer decreased by 29% in Northern Ireland and by 26% in the Republic of Ireland; by 25% in the Netherlands and by 20% in Belgium and 25% in Flanders; and by 16% in Sweden and by 24% in Norway. The time trend and year of downward inflexion were similar between Northern Ireland and the Republic of Ireland and between the Netherlands and Flanders. In Sweden, mortality rates have steadily decreased since 1972, with no downward inflexion until 2006. Countries of each pair had similar healthcare services and prevalence of risk factors for breast cancer mortality but differing implementation of mammography screening, with a gap of about 10-15 years.
Conclusions: The contrast between the time differences in implementation of mammography screening and the similarity in reductions in mortality between the country pairs suggest that screening did not play a direct part in the reductions in breast cancer mortality.

Mother-daughter communication about mammography in an Australian sample

Breast cancer is a significant health problem for aging women. Despite constant efforts to promote mammography in Australia to facilitate early detection, screening rates through the national mammography screening service remain at just 57%. Based on a theoretical rationale informed by Family Communication Patterns theory, the current study used semi-structured interviews with Australian mother-daughter dyads (N = 8) to examine their health communication, with a view to exploring the potential for daughters to deliver mammography promotion messages to their mothers. Consistent with results of previous studies conducted in different cultural contexts, the Australian mothers and daughters in this sample frequently communicated about health topics. Daughters were a source of information and influence for their mother's health decision making. The delivery of mammography promotion messages to the mother by the daughter may be most successful for dyads that value bidirectional conversation. Aspects of the Australian culture may facilitate the success of this strategy.

Effectiveness, costs, and cost-effectiveness of recruitment strategies for a mammographic screening program to detect breast cancer

BACKGROUND AND PURPOSE: Since effective and affordable recruitment methods are essential for the widespread implementation of mammographic screening for detection of breast cancer, we studied the effectiveness, the costs, and the cost-effectiveness of various recruitment strategies in the population targeted by a pilot Australian program that offered free mammography screening between 1988 and 1990. METHODS: We evaluated three public recruitment strategies--local newspaper articles, community promotion, and promotion to physicians--and five personal strategies--invitation letters with or without specified appointment times, either alone or with a follow-up letter, or telephone call to nonattenders. The effectiveness of public recruitment strategies was estimated from monthly attendance rates by Poisson regression analysis, while the probability of attendance in response to personal strategies was calculated using logistic regression analysis. Costs were determined by resource usage studies. The cost-effectiveness ratios for personal strategies were determined using decision analysis. RESULTS: The costs in 1988-1989 Australian dollars per woman recruited were $22 for local newspaper articles and $106 for community promotion. No detectable increase in attendance resulted from promotion to physicians. When the cost of reserving an appointment was considered, the most cost-effective personal recruitment strategy was an invitation letter without a specified appointment time, followed by a second letter to nonattenders. This strategy recruited 35.6% of women in the sample targeted and cost $10.52 per attendee. In comparison, the most effective personal recruitment strategy was a letter with a specified appointment time followed by a second letter to nonattenders, which recruited 44.1% of women at an average cost of $19.99 and a marginal cost of $59.71 per additional attendee. CONCLUSIONS: Personal recruitment strategies were more cost-effective than public strategies. The most cost-effective personal strategy was an invitation letter without a specified appointment time, followed by a second letter to nonattenders.

Cancer screening - principles, evaluation and implementation

Screening for malignant disease aims to reduce the population risk of impaired health due to the tumor in question. Screening does not only entail testing but covers all steps required to achieve the intended reduction in risk, from the appropriate information of the population to a suitable therapy. Screening tests are performed in individuals free or unaware of any symptoms associated with the tumor. An essential condition is a recognizable pathological abnormality, which occurs without symptoms and represents a pre-clinical, early stage of the tumor. Overdiagnosis and overtreatment have only recently been recognized as important problems of screening for malignant disease. Overdiagnosis is defined as a screening-detected tumor that would never have led to symptoms. In prostate-specific antigen (PSA) screening for prostate cancer 50 % - 70 % of screening-detected cancers represent such overdiagnoses. Similarly, in the case of mammography screening 20 % - 30 % of screening-detected breast cancers are overdiagnoses. The evaluation of screening interventions is often affected by biases such as healthy screenee effects or length and lead time bias. Randomized controlled trials are therefore needed to examine the efficacy and effectiveness of screening interventions and to define the rate of adverse outcomes such as unnecessary diagnostic evaluations, overdiagnosis and overtreatment. Unfortunately there is no independent Swiss body comparable to the National Screening Committee in the United Kingdom or the United States Preventive Services Task Force, which examines screening tests and programs and develops recommendations. Clearly defined goals, a central organization responsible for inviting eligible individuals, documentation and quality assurance and balanced information of the public are important attributes of successful screening programs. In Switzerland the establishment of such programs is hampered by the highly fragmented, Federal health system which allows patients to access specialists directly.

Mammografie-Screening

Nur wenige Vorsorgeuntersuchungen sind so umfassend in randomisiert-kon- trollierten Studien (RCTs) untersucht worden wie das Screening auf Brustkrebs mit Hilfe der Mammografie. Es liegen derzeit acht große randomisiert-kontrol- lierte Studien und mehrere Meta-Analysen vor. Letztere kommen mehrheitlich zum Schluss, dass sich die Brustkrebssterblichkeit durch Mammografie-Screening um etwa 20 % senken lässt. Dies bedeutet im Schweizer Kontext, dass etwa 1 von 1'000 Frauen weniger an Brustkrebs stirbt, wenn Frauen ab dem 50. Lebensjahr zehn Jahre lang gescreent werden. Andererseits führt das Screening auch zu Überdiagnosen und Übertherapien. So nimmt die Zahl der Brustkrebsdiagnosen um etwa 20 % zu, was zu einer entsprechenden Zunahme an chirurgischen Ein- griffen, Strahlen- und Chemotherapien führt. Über zehn Jahre gerechnet, erhal- ten etwa 4 von 1'000 Frauen eine Brustkrebsdiagnose, die sie ohne Screening nicht erhalten hätten. Etwa 200 von 1'000 Frauen sind im Verlaufe von zehn Jahren (fünf Screening-Runden) mit abklärungsbedürftigen Befunden konfron- tiert, wobei es sich dabei mehrheitlich um falsch positive Befunde handelt. Gleichzeitig werden auch mit einem Screening-Programm 20 bis 30 % der Brust- krebse nicht im Screening erfasst. Die Information der Bevölkerung bezüglich des Mammografie-Screenings ist derzeit noch mangelhaft. Dies führt dazu, dass der mögliche Nutzen von den betroffenen Frauen überschätzt und der Schaden unterschätzt wird. Die Aufklärung der Bevölkerung im Hinblick auf Nutzen und Risiken des Mammografie-Screenings muss daher verbessert werden, denn Frau- en haben einen Anspruch auf evidenzbasierte Informationen und eine „infor- mierte Entscheidung“.

Comment on: ‘Screening’ for Breast Cancer: Misguided Research Misinforming Public Policies, by O. S. Miettinen

Our commentary of the article “‘Screening’ for Breast Cancer: Misguided Research Misinforming Public Policies” has two main parts. First we address some of the methodological points raised by Professor Miettinen. Then we review more specific aspects of the Swiss Medical Board statement on mammography screening for early detection of breast cancer.

Determining the association between nativity status and mammography utilization among women in the United States using 2000 and 2005 NHIS data

Objective. To determine the association between nativity status and mammography utilization among women in the U.S. and assess whether demographic variables, socioeconomic factors healthcare access, breast cancer risk factors and acculturation variables were predictors in the relationship between nativity status and mammography in the past two years. ^ Methods. The NHIS collects demographic and health information using face-to-face interviews among a representative sample of the U.S. population and a cancer control module assessing screening behaviors is included every five years. Descriptive statistics were used to report demographic characteristics of women aged 40 and older who have received a mammogram in the last 2 years from 2000 and 2005. We used chi square analyses to determine statistically significant differences by mammography screening for each covariate. Logistic regression was used to determine whether demographic characteristics, socioeconomic characteristics, healthcare access, breast cancer risk factors and acculturation variables among foreign-born Hispanics affected the relationship between nativity status and mammography use in the past 2 years. ^ Results. In 2000, the crude model between nativity and mammography was significant but results were not significant after adjusting for health insurance, access and reported health status. Significant results were also reported for years in U.S. and mammography among foreign-born born women. In 2005, the crude model was also significant but results were not significant after adjusting for demographic factors. Furthermore, there was a significant finding between citizenship and mammography in the past 2 years. ^ Conclusions. Our study contributes to the literature as one of the first national-based studies assessing mammography in the past two years based on nativity status. Based on our findings, health insurance and access to care is an important predictor in mammography utilization among foreign-born women. For those with health care access, physician recommendation should further be assessed to determine whether women are made aware of mammography as a means to detect breast cancer at an early stage and further reduce the risk of mortality from the breast cancer.^

The effect of obesity on mammography utilization in African American women

Breast cancer continues to reign as a common cause of death for women in the United States, claiming the lives of more than an estimated 40,000 women in 2009 alone (Ries et al., 2009). A mammogram, an x-ray of the breast, can aid in early detection of breast cancer and thus more successful treatment. Screening patterns indicate African American women are less likely to utilize mammography technology when compared to their Caucasian counterparts. Additionally, the obesity epidemic in the United States remains a major public health problem. Obesity trends indicate that African American women are likely to be more obese when compared to Caucasian women. Pischon, Nöthlings, & Boeing (2008) concluded there was sufficient evidence linking breast cancer and obesity. Many researchers have identified obesity as a risk factor for breast cancer. As African American women are disproportionately burdened by both breast cancer mortality and obesity, more extensive research is needed to gain more knowledge about their association. The purpose of this study was to identify the role obesity plays in lessening an African American woman’s usage of mammography technology. Data from the 2005 National Health Interview Study were analyzed using SPSS to evaluate the relationship between body mass index (BMI) and mammography utilization in the two aforementioned populations.^ After excluding respondents from the sample who did not meet the set criteria, there were 17,666 women remaining. Of the 17,666 women, 6,156 (34.8%) had a healthy weight, 6,024 (34.1%) were overweight, and 4,285 (24.3%) were obese. About 70% of the sample population reported having had a mammogram in the last two years. Another 27.6% of women reported not receiving a mammogram within this same two year time frame. Within ethnic categories, the majority of the sample was Caucasian (64.2%) while only 15.1% of the sample was African American. The relationship between mammography usage and body mass index was not statistically significant within any body mass index categories. When analyzing the relationship between mammography usage and BMI, adjusting for ethnicity, there was also no significant difference between obese African American and obese Caucasian women. The study did find significant relationships between mammography usage and body mass index when adjusting for cancer risk OR = .79 (95% CI .72 - .85), and marital status OR = 1.18 (95% CI 1.05 - 1.34). Due to insignificant findings, there was no evidence to support the hypothesis regarding differences in mammography usage based on weight or ethnicity. Mammography screening differences based on ethnicity are widely cited. Unfortunately it is still unclear exactly where these differences lie. Obesity has been widely documented in the literature as a risk factor for many chronic diseases, including certain forms of cancer. Understanding the relationship between screening behaviors and weight can assist in the development of health promotion programs aimed at high risk groups. In order to change screening behavior and reduce mortality from breast cancer, more research is needed to identify similarities within low screening populations.^

Trusting technology: Women aged 40-49 years participating in screening for breast cancer - an exploratory study

Objective: This paper reports key findings from an exploratory study of factors associated with women's decision to participate in mass mammography screening in Tasmania. In particular, we explored factors that contribute to the choice to participate in screening by women who are outside the primary target group, and for whom the evidence of benefit remains contentious. Methods: Semi-structured interviews were conducted with a small sample of women aged between 40 and 49 years in rural Tasmania who had participated in mammography screening. Results: Key ideas that appeared to shape participation included the fear of breast cancer, trust in technology, and taking responsibility for health. Information provision is also an important factor in shaping participation patterns. Conclusions and implications: In order to facilitate informed consent, information provision in this area should take account of the dominant ideas that shape the decision to participate in breast cancer screening.

Using fear appeals to promote cancer screening - are we scaring the wrong people?

There is debate regarding the use of fear appeals (emphasizing severe threats to health) in social marketing, to encourage preventive behaviours, such as screening for breast cancer. While it has been found that fear appeals may result in attitude and behaviour change there is also the risk of inciting inappropriate levels of fear, motivating the wrong audience or instigating maladaptive behaviour in the target group such as denial or defensive avoidance. This study examined the impact of an experimental threat manipulation for mammography screening on a group of women in regional Australia. The study found that varying the level of threat had no impact on stated intentions of the women to undergo mammographic screening. However, it also found that high-threat messages resulted in stronger negative emotional reactions and greater perceived susceptibility among younger women who are not the target group for screening in Australia. The results of this study emphasize the importance of limiting the use of high levels of threat in social marketing campaigns, and ensuring that campaigns are appropriately designed to specifically impact upon and motivate the target group. Copyright © 2006 John Wiley & Sons, Ltd.

Feasibility of using technology to disseminate evidence to rural nurses and improve patient outcomes

Background: Rural African American women receive less frequent mammography screening and die of breast cancer at a higher rate than is seen in the general population. To overcome this disparity, it is necessary to assist rural providers in their efforts to influence women to obtain screening. Method: This study examined the feasibility of using distance education to disseminate knowledge about timely and appropriate mammography screening to rural nurses, using patient outcome data to evaluate the effectiveness of this intervention. Results: Overall, there was a decline in referrals and mammography screening, but the intervention group centers showed a smaller decline after the educational intervention than did the control group. Conclusion: The findings show the effect of dissemination of information and the feasibility of using patient outcome data for educational evaluation. Neighboring academic health centers and nursing schools should include in their mission the provision of educational programs for relatively isolated rural nurses.

Early diagnosis of breast cancer

The greatest effect on reducing mortality in breast cancer comes from the detection and treatment of invasive cancer when it is as small as possible. Although mammography screening is known to be effective, observer errors are frequent and false-negative cancers can be found in retrospective studies of prior mammograms. In the year 2001, 67 women with 69 surgically proven cancers detected at screening in the Mammography Centre of Helsinki University Hospital had previous mammograms as well. These mammograms were analyzed by an experienced screening radiologist, who found that 36 lesions were already visible in previous screening rounds. CAD (Second Look v. 4.01) detected 23 of these missed lesions. Eight readers with different kinds of experience with mammography screening read the films of 200 women with and without CAD. These films included 35 of those missed lesions and 16 screen-detected cancers. CAD sensitivity was 70.6% and specificity 15.8%. Use of CAD lengthened the mean time spent for readings but did not significantly affect readers sensitivities or specificities. Therefore the use of applied version of CAD (Second Look v. 4.01) is questionable. Because none of those eight readers found exactly same cancers, two reading methods were compared: summarized independent reading (at least a single cancer-positive opinion within the group considered decisive) and conference consensus reading (the cancer-positive opinion of the reader majority was considered decisive). The greatest sensitivity of 74.5% was achieved when the independent readings of 4 best-performing readers were summarized. Overall the summarized independent readings were more sensitive than conference consensus readings (64.7% vs. 43.1%) while there was far less difference in mean specificities (92.4% vs. 97.7%). After detecting suspicious lesion, the radiologist has to decide what is the most accurate, fast, and cost-effective means of further work-up. The feasibility of FNAC and CNB in the diagnosis of breast lesions was compared in non-randomised, retrospective study of 580 (503 malignant) breast lesions of 572 patients. The absolute sensitivity for CNB was better than for FNAC, 96% (206/214) vs. 67% (194/289) (p < 0.0001). An additional needle biopsy or surgical biopsy was performed for 93 and 62 patients with FNAC, but for only 2 and 33 patients with CNB. The frequent need of supplement biopsies and unnecessary axillary operations due to false-positive findings made FNAC (294 ) more expensive than CNB (223 ), and because the advantage of quick analysis vanishes during the overall diagnostic and referral process, it is recommendable to use CNB as initial biopsy method.

Sentinel lymph node biopsy as a diagnostic tool in the treatment of breast cancer

The purpose of this study was to evaluate the use of sentinel node biopsy (SNB) in the axillary nodal staging in breast cancer. A special interest was in sentinel node (SN) visualization, intraoperative detection of SN metastases, the feasibility of SNB in patients with pure tubular carcinoma (PTC) and in those with ductal carcinoma in situ (DCIS) in core needle biopsy (CNB) and additionally in the detection of axillary recurrences after tumour negative SNB. Patients and methods. 1580 clinically stage T1-T2 node-negative breast cancer patients, who underwent lymphoscintigraphy (LS), SNB and breast surgery between June 2000 - 2004 at the Breast Surgery Unit. The CNB samples were obtained from women, who participated the biennial, population based mammography screening at the Mammography Screening Centre of Helsinki 2001 - 2004.In the follow- up, a cohort of 205 patients who avoided AC due to negative SNB findings were evaluated using ultrasonography one and three years after breast surgery. Results. The visualization rate of axillary SNs was not enhanced by adjusting radioisotope doses according to BMI. The sensitivity of the intraoperative diagnosis of SN metastases of invasive lobular carcinoma (ILC) was higher, 87%, with rapid, intraoperative immunohistochemistry (IHC) group compared to 66% without it. The prevalence of tumour positive SN findings was 27% in the 33 patients with breast tumours diagnosed as PTC. The median histological tumour size was similar in patients with or without axillary metastases. After the histopathological review, six out of 27 patients with true PTC had axillary metastases, with no significant change in the risk factors for axillary metastases. Of the 67 patients with DCIS in the preoperative percutaneous biopsy specimen , 30% had invasion in the surgical specimen. The strongest predictive factor for invasion was the visibility of the lesion in ultrasound. In the three year follow-up, axillary recurrence was found in only two (0.5%) of the total of 383 ultrasound examinations performed during the study, and only one of the 369 examinations revealed cancer. None of the ultrasound examinations were false positive, and no study participant was subjected to unnecessary surgery due to ultrasound monitoring. Conclusions. Adjusting the dose of the radioactive tracer according to patient BMI does not increase the visualization rate of SNs. The intraoperative diagnosis of SN metastases is enhanced by rapid IHC particularly in patients with ILC. SNB seems to be a feasible method for axillary staging of pure tubular carcinoma in patients with a low prevalence of axillary metatastases. SNB also appears to be a sensible method in patients undergoing mastectomy due to DCIS in CNB. It also seems useful in patients with lesions visible in breast US. During follow-up, routine monitoring of the ipsilateral axilla using US is not worthwhile among breast cancer patients who avoided AC due to negative SN findings.