Mammography Recommendations Research Articles

Breast and ovarian cancer screening practices in healthy women with a strong family history of breast or ovarian cancer.

Studies in women with a family history of cancer demonstrate a wide variability in the uptake of cancer screening measures. Little data exist regarding the breast and ovarian cancer screening practices of women who are members of hereditary breast cancer families. In order to address this issue, we examined the screening behaviors and the determinants of screening in a clinic based group of 216 women with a strong family history of breast or ovarian cancer who were participating in a free genetic counseling and testing research program. At baseline, prior to obtaining genetic counseling or testing, 50% of women ages 30-39, 83% of those age 40-49, 69% of those 50-64, and 53% of those >65 reported having a mammogram in the prior year. Adherence to mammography recommendations was correlated with age, number of relatives with breast cancer, and income. Twenty percent of participants had at least one CA- 125 performed and 31 % had ever obtained a screening ultrasound. Having at least one relative with ovarian cancer was very strongly associated with ovarian cancer screening [OR = 12.3, 95% CI = 4.6-33 for CA-125; OR=4.9, 95% CI=2.4, 10.1 for ultrasound]. No association between cancer worries/distress and either breast or ovarian cancer screening was found. In conclusion, the breast and ovarian screening uptake in healthy women from hereditary breast cancer families is suboptimal, even for women over age 50, for whom annual mammography is clearly indicated. These findings indicate a need for better education about screening guidelines for high-risk women.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population. In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties. Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income). Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

Multiple bilateral masses detected on screening mammography: assessment of need for recall imaging.

When multiple bilateral partially circumscribed masses having a similar appearance are detected on screening mammography, some radiologists recommend recall examination to identify imaging features suggestive of malignancy that are not evident on standard screening views. This study assesses the need for such recall imaging. Cases of multiple masses were identified by reviewing the mammographic reports of 84,615 consecutive screening examinations. Each case of multiple masses was prospectively interpreted as benign, with recommendations for follow-up mammography in 1 year and for aspiration of any palpable masses if clinically indicated. Subsequently diagnosed cancers were identified through data linkage with our regional tumor registry and through our institution's computer-based outcomes tracking system. Among 84,615 consecutive screening examinations, we identified 1440 (1.7%) cases of multiple masses. Among the multiple-masses cohort, two interval cancers were found. Both were early-stage (T1bN0M0; T1cN0M0) and low-grade (histologic grade 1) cancers. The interval cancer rate among the multiple-masses cohort was 0.14%, which is somewhat lower than the age-matched United States incident cancer rate of 0.24%. The frequency of cancer development and the stage at cancer diagnosis among nonrecalled cases of multiple masses are similar to those observed in the general screening mammography population. Therefore, recall imaging for women with multiple masses does not appear to be justified.

Health care reform in Oregon: the impact of the Oregon Health Plan on utilization of mammography

Background: In 1994, Oregon implemented the Oregon Health Plan (OHP), extending health care coverage under a system of capitated managed care to uninsured citizens living below the Federal Poverty Level (FPL). We conducted a study to measure receipt of clinical preventive services among women newly enrolled in the OHP. Methods: Six hundred and sixty six women aged 52–64, and living below the FPL in Oregon were randomly selected from OHP enrollment rosters and interviewed by telephone. A follow-up survey was conducted 1 year later. The main outcome of interest was receipt of a screening mammogram during the first year in the OHP. Results: At enrollment 17% (65/383) of participants had never had health care coverage. Sixty-six percent of the women (220/333) were overdue for a mammogram. Fifty-five percent (121/220) reported cost as the main reason they had not had this procedure. Mammography rates doubled under the OHP (21% to 52%, 95% CI = 0.25–0.38, p < 0.001). Among women who were overdue for a mammogram at the time they enrolled, an expressed plan to get a mammogram (OR3.0, 95% CI = 1.1–8.7, p = 0.04), citing cost as the main reason for being overdue (OR3.0, 95% CI = 1.3-7.2, p = 0.014), receipt of a routine checkup (OR9.5, 95%CI = 3.7–24.9, p < 0.001), and health care provider’s (HCP’s) recommendation for mammography (OR8.1, 95% CI = 2.9–23.0, p < 0.001) were independently associated with receipt of a mammogram.. Conclusion: The OHP enrolled and successfully delivered clinical preventive services to a medically under served population. Even after removing the financial barrier, obstacles to mammography remain. These may be overcome by health systems changes to insure receipt of routine checkups and appropriate provider recommendations.

Benign Diagnosis by Image-Guided Core-Needle Breast Biopsy

Image-guided core-needle breast biopsy (IGCNBB) is widely used to evaluate patients with abnormal mammograms; however, information is limited regarding the reliability of a benign diagnosis. The goal of this study was to demonstrate that a benign diagnosis obtained by IGCNBB is accurate and amenable to mammographic surveillance. Records of all patients evaluated by IGCNBB from July 1993 through July 1996 were reviewed. Biopsies were classified as malignant, atypical, or benign. All benign cases were followed by surveillance mammography beginning 6 months after IGCNBB. Of the 1110 patients evaluated by IGCNBB during the study period, 855 revealed benign pathology. A total of 728 of the 855 patients (85%) complied with the recommendation for surveillance mammography. A total of 196 IGCNBBs were classified as malignant; 59 cases were classified as atypical. The atypical cases were excluded from the statistical analysis. Only two patients have demonstrated carcinoma after a benign IGCNBB during the 2-year minimum follow-up period. The sensitivity and specificity of a benign result were 100.0 and 98.9 per cent, respectively. A benign diagnosis obtained by IGCNBB is accurate and therefore amenable to mammographic surveillance. The results of this study support IGCNBB as the preferred method of evaluating women with abnormal mammograms.

Breast cancer screening uptake in women at increased risk of developing hereditary breast cancer.

This multicenter study assessed breast cancer screening uptake in 461 unaffected women at increased risk of developing breast cancer on the basis of family history who approached familial cancer clinics for advice about surveillance options. At the time of attending the clinic, 89% and 90% of participants were vigilant with respect to age- and risk-specific recommendations for mammography and clinical breast examination, respectively, and 51% reported practicing breast self-examination monthly or more frequently. The degree to which health outcomes are perceived to be under one's personal control (chi2 = -2.09, p = 0.0037) and breast cancer anxiety (chi2 = 8.11, p = 0.044) were both associated with monthly or more frequent breast self-examination, while there were no associations with sociodemographic characteristics. A significantly lower percentage (56%) of women aged <30 were vigilant with respect to mammography recommendations, compared to 77%, 96% and 98% of women aged 30-39, 40-49 and >50, respectively (chi2 = 37.2, p < 0.0001). These relatively low rates of mammographic screening in young women may reflect concerns about increased cancer risk associated with early and repeated radiation exposure or lack of sensitivity in young women with radiographically dense breasts. If mammographic screening is ultimately shown to lower mortality in women at high risk, there will be a strong case to promote screening in young women. The need for regular mammographic screening would then need to be highlighted and reinforced amongst young women and their referring physicians. Awareness amongst general practitioners, who are largely responsible for referral to screening services, would also need to be increased.

Clinical value of mammography for symptomatic women 35 years of age and younger

Objective: This retrospective observational study was designed to answer the following question: Is mammography clinically effective in the evaluation of women ≤35 years old with breast symptoms or findings? Study Design: A retrospective review was undertaken of 1908 consecutive initial mammogram reports of symptomatic women ≤35 years old who came to a referral breast clinic. The clinic records were analyzed for the working diagnoses and management plans before and after the input of the initial mammogram reports. Results: Of the 4160 initial mammograms of women who came (1992-1995) to the Breast Diagnostic Center at Women’s and Children Hospital, Los Angeles, Calif, 1908 were of women ≤35 years old. The mammogram reports were reviewed and tabulated by age group for mammography recommendations. The working diagnoses and management plans in the center’s charts were retrospectively evaluated before and after the mammogram reports to ascertain whether the mammogram reports altered clinical management in this patient population and age group. No clinically unsuspected cancers were perceived by mammography performed at the center in women ≤35 years old. (All of the 23 invasive cancers were palpable and had prior diagnoses after fine-needle aspiration biopsy.) The initial mammogram reports did not change the working diagnosis or clinical management of these cases in this patient population and clinic setting. Ultrasonography was recommended by the radiologists in 37% of the study cases. Conclusions: Routine initial mammography was not cost-effective or clinically beneficial in the evaluation of breast symptoms or findings and management of the cases of women ≤35 years old who came to our center. (Am J Obstet Gynecol 1999;180:1484-90.)

Compliance with Mammography Guidelines: Physician Recommendation and Patient Adherence

Background.Guidelines recommend that women ages 50–75 years receive screening mammography every 1–2 years. We related receipt of physician recommendations for mammography and patient adherence to such recommendations to several patient characteristics.Methods.We retrospectively reviewed medical records of 1,111 women ages 50–75 attending three clinics in an urban university medical center. We ascertained overall compliance with mammography guidelines and two components of compliance: receipt of a physician recommendation and adherence to a recommendation. Outcome measures were the proportion of patients demonstrating each type of compliance and adjusted odds ratios, according to several patient-related characteristics.Results.Overall, 66% of women received a recommendation. Of women receiving a documented recommendation, 75% adhered. Factors showing significant positive associations with receiving a recommendation included being a patient in the general internal medicine clinic, having private insurance, visiting the clinic more often, and having a recent Pap smear. Patient adherence was positively associated with private insurance and Pap smear history, negatively associated with internal medicine, and not associated with visit frequency.Conclusions.Patient factors influencing physician mammography recommendations may be different from those associated with patient adherence, except for having private health insurance, which was a predictor of both.

Underusers of Mammogram Screening: Stage of Adoption in Five U.S. Subpopulations

Background. The purpose of this report is to describe the characteristics of women ages 50 to 80 who do not follow commonly accepted mammography screening guidelines. It provides unique understanding of the robustness of characteristics of underusers across five different U.S. subpopulations.Methods. The data are from the baseline surveys of the five studies of the NCI Breast Cancer Screening Consortium. Stage of adoption of mammography screening and other characteristics of underusers are presented. Polytomous logistic regression analysis was used to explore multivariable associations with stage of adoption in each study site.Results. The five samples studied by the Consortium range in size from 259 to 4,477 women (n= 11,292). The relationship of the perceptions of the pros and cons of mammography with stage of adoption was strikingly similar across the five samples. Other variables consistently associated with stage were a recent receipt of a breast physical examination and recommendation for mammography by a physician.Conclusions. The findings suggest a need to encourage regular screening through effective communication from a health care provider. Intervention messages should be designed to increase the pros of mammography, decrease the cons, and highlight these differentially according to the woman's stage of adoption.

The National Cance Advisory Board

The National Cance Advisory Board

Final mammography recommendation?

Final mammography recommendation?

Final Mammography Recommendation?

THE National Cancer Institute (NCI) has accepted a recommendation from its advisory board that women in their 40s who are at average risk of breast cancer get a screening mammogram every 1 to 2 years. The decision by the NCI reverses its position, promulgated at a National Institutes of Health (NIH) consensus conference earlier this year ( JAMA . 1997; 277:519-520), that routine mammography is not indicated for women in their 40s. The recommendation from the National Cancer Advisory Board, appointed by President Clinton, promises to defuse a politically controversial issue. Previously, the NCI said the data were not strong enough to justify recommending populationwide, routine mammographic screening of women in this age group. When the NIH consensus conference in January essentially reaffirmed this position, its report set off protests from breast cancer screening advocates and their congressional supporters. Richard Klausner, MD, NCI director, asked the institute's 18-member advisory board to take

The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium.

It is not certain whether older women with additional breast carcinoma risk factors are adequately screened or whether they are more likely to undergo screening than other older women. This study was conducted to determine whether selected risk factors influence the breast carcinoma screening rates of Medicare-insured older women (i.e., age 65 years or older). Self-reported rates of screening mammography and clinical breast examination in the previous year were compared for women with benign breast disease, women with a family history of breast carcinoma, and women lacking these risks, using samples of non-Hispanic white, Medicare-insured women surveyed at the 5 National Cancer Institute Breast Cancer Screening Consortium sites in 1991 (n = 5376, mean age = 69.7 years) and 1994 (n = 5086, mean age = 69.7 years). In 1993, rates of screening mammography reported in the previous year at the 5 Consortium sites had a range of 46-61% for women with a family history of breast carcinoma, 49-66% for women with benign breast disease, and 31-43% for women lacking these risks. Women with a positive family history or a personal history of benign breast disease were also more likely to report having had a clinical breast examination in the previous year and having received a physician's mammography recommendation. A substantial proportion of older women with a positive family history remain inadequately screened, however. Between 25% and 35% of women in this group had not had a screening mammogram in the previous 2 years, while at some Consortium sites more than 20% reported never having had a mammogram in their lives. Older women with additional risk factors are more likely to undergo screening mammography. This is due partly to more frequent physician recommendations for screening and partly to more frequent provision of clinical breast examinations. However, a substantial proportion of high risk older women remain inadequately screened, despite widespread clinical consensus that these women should be regularly screened. Interventions that target older women with risk factors and their physicians appear warranted. Understanding the mechanisms by which risk factors influence screening is an important area for future research.

The simultaneous analysis of patient, physician and group practice influences on annual mammography performance

The current study examined the relationship of several variables at the patient ( n = 2780), physician ( n = 166), and group practice ( n = 45) levels for predicting receipt of annual mammography screening. Patient-level variables included constructs from the Triandis Model of Choice; physician-level variables included measures of barriers and receptiveity to prevention, as well as demographic information. Hierarchical modeling demonstrated that variables at the patient and physician level reliably predict annual mammography screening, while frequency of screening did not vary across group practices after accounting for patient and physician variables. Patient-level predictors included social norms, perceived consequences and perceived barriers. The only physician-level predictor identified was annual mammography recommendation. These findings add to data which emphasize the importance of public education and social support in health maintenance activities.

Mammography in older women: one-time and three-year adherence to guidelines.

A survey examined self-reported mammography use in a convenience sample of 1,083 women 50 years of age and over. Relationships were examined between ever having mammography; 3-year adherence to mammography guidelines; the predisposing variables of attitudes, knowledge, health history factors, and selected demographics; and the enabling variables of income, health insurance, source of regular medical care, and type of regular physician. Logistic regression analysis for ever having a mammogram identified significant odds ratios (OR) > 1 (p < or = .05) for doctor recommendation for mammography (OR = 14.26), satisfaction with way of living (OR = 2.77), perceived benefits of mammography (OR = 1.35), and knowledge (OR = 1.21). Odds ratios < 1 were found for scaled variables of barriers and control (OR = .81 and .65, respectively). For 3-year adherence, significant odds ratios > 1 were annual Pap tests (OR = 3.36), willingness to pay > or = $50 for mammography (OR = 2.00), benefits (OR = 1.20), and knowledge (OR = 1.18). The odds ratio for control was significant at .85.

Variation in recommendations for breast and cervical cancer screening among primary care physicians in North Carolina, 1991.

Physicians play an important role in recommending and doing cancer screening for their patients. In 1991, the North Carolina Department of Environment, Health and Natural Resources and the Centers for Disease Control and Prevention conducted a survey to determine the counseling and referral practices of primary care physicians practicing in North Carolina. Physicians were asked to report the percentage of patients in various age groups that they recommended receive a clinical breast examination, referral for mammography screening, or a Pap test and at what intervals they recommended each study. They were also asked their perceived barriers to cervical cancer screening. Obstetrician-gynecologists recommended annual Pap smear screening more frequently than did physicians in other specialties for patients of all ages. For mammography, variation existed for recommended screening intervals for all specialties by patient age (35 to 39 years, 40 to 49 years, 50 to 64 years, and over age 65). Recommendations for mammography also differed significantly according to physicians' age and sex. The medical community and the public need a consistent and clear message to promote effective screening maneuvers.

Recent mammography in women aged 35 and older: predisposing variables.

Early detection through regular mammography screening is the most effective way to decrease mortality from breast cancer. Our purpose in writing this report was to identify factors that influenced women to adhere to mammography guidelines within the year prior to the study. A sample of 581 women aged 35 years and older was used. Data were collected during in-home interviews led by graduate research assistants. Results indicated that the predisposing variables of seriousness, benefits, health motivation, control, knowledge of breast cancer and mammography guidelines, socioeconomic status, age, physician recommendation for mammography, and prior breast symptoms were significantly related to having had recent mammography.

Adherence to screening mammography recommendations in a university general medicine clinic

To determine factors predicting adherence to a health care provider's screening mammography recommendation in a general internal medicine practice. Prospective observational study. An urban academic general internal medicine practice. Three hundred forty-nine asymptomatic women, aged 50 years and older, without prior history of breast cancer, who received a health care provider's recommendation for screening mammography. Independent variables were: patient age, race, insurance type, educational level, and duration of affiliation with the practice; visit type; and health care provider gender and level of training. Dependent variables were acceptance of the recommendation and adherence, defined as undergoing mammography within three months of the recommendation. Overall, 193 (55%) of the women underwent the recommended mammography. Two hundred ninety-eight (85%) initially agreed to the recommendation, and of these, 190 (64%) completed mammography within three months. By univariate analysis, acceptance of the recommendation decreased significantly with increasing age (p < 0.01), and by race (African-Americans 89% vs whites 82%, p = 0.05). Only age remained independently predictive of acceptance in a multiple variable analysis. Among women who accepted the recommendation, adherence varied significantly according to race (white 70% vs nonwhite 59%, p = 0.05), insurance type [Medicare as only insurance 45%, Medicaid 66%, non-health maintenance organization (non-HMO) private 62%, HMO 73%, p = 0.03], and health care provider training (attending physicians 73%, residents 58%, nurse practitioners 47%, p = 0.02). In a logistic regression analysis, insurance type and health care provider training remained independently predictive of adherence. Acceptance of screening mammography recommendations decreases with age. Among the women who agreed to the recommendation for screening mammography, insurance type and health care provider level of training best predicted adherence.

Breast disease

Breast diseases are a common aspect of primary care practice. Common benign and malignant breast diseases are reviewed. The evaluation of common breast problems is presented and current recommendations for diagnostic and screening mammography are discussed.