Abstract
BackgroundSuccessful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes.MethodsA systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design.ResultsEighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2–33% and 27.3–71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient’s results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up.ConclusionsFollow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up.
Highlights
Successful breast cancer screening relies on timely follow-up of abnormal mammograms
The search strategy was an intersection of Medical Subject Headings (MeSH) terms referring to “family practice” or “primary care”, “delay”/“follow-up”/“errors” and “screening”/“cancer screening” tests for breast, colorectal, gynaecological, prostate, lung, liver and skin cancer to capture all relevant articles related to inadequate follow-up of abnormal tests results for these cancers to enable a series of systematic reviews to be performed examining inadequate follow-up for each respective cancer
Studies not included in this review found inconsistencies between age and abnormal mammogram follow-up: Haas et al found timely follow-up of abnormal screening or diagnostic mammograms was higher in women > 50 years [59]; whereas Kaplan et al found age was not a significant predictor of follow-up in women with breast symptoms and/or an abnormal mammogram [50]
Summary
Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. A comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. Mammographic screening relies on the follow-up of abnormal (potentially clinically significant) mammograms in a timely manner. Breast screening guidelines in the United States (US) and Europe recommend women receive notification of abnormal mammogram results within five days of the primary care provider’s (PCP’s) receipt of results [7, 8]. In Australia and the Netherlands, clinical guidelines recommend women should receive mammogram results within 28 days and 14 days of screening, respectively [9, 10]. To guide follow-up, American College of Radiology (ACR) Breast Imaging Reporting and Data System® (BIRADS®) is used to classify mammograms, with highly suggestive of malignancy (BIRADS®-5), suspicious malignancy (BIRADS®4) or indeterminant (BIRADS®-0) mammograms recommended immediate (within 3 months) follow-up and likely benign (BIRADS®-3) mammograms recommended short term (3–6 months) follow-up [7, 11]
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