Effects of False-Positive Screening Mammograms
breast screening result groups five months after their last breast screening appointment. J Public Health Med. 1998;20(4):396-403. 10. Brett J, Bankhead C, Henderson B, Watson E, Austoker J. The psychological impact of mammographic screening: a systematic review. Psychooncology. 2005;14(11):917-938. 11. Brewer NT, Salz T, Lillie SE. Systematic review: the long-term effects of false-positive mammograms. Ann Intern Med. 2007;146(7):502510. 12. Brodersen J, Thorsen H, Cockburn J. The adequacy of measurement of short and long-term consequences of false-positive screening mammography. J Med Screen. 2004;11(1):39-44. 13. Burman ML, Taplin SH, Herta DF, Elmore JG. Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization. Ann Intern Med. 1999;131(1):1-6. 14. Castells X, Molins E, Macià F. Cumulative false positive recall rate and association with participant related factors in a population based breast cancer screening programme. J Epidemiol Community Health. 2006;60(4):316-321. 15. Christiansen CL, Wang F, Barton MB, et al. Predicting the cumulative risk of false-positive mammograms. J Natl Cancer Inst. 2000;92(20): 1657-1666. 16. Currence BV, Pisano ED, Earp JA, et al. Does biopsy, aspiration or six-month follow-up of a false-positive mammogram reduce future screening or have large psychosocial effects? Acad Radiol. 2003;10(11):1257-1266. 17. Sickles EA. False positive rate of screening mammography. N Engl J Med. 1998;339(8):561-562, author reply 563. 18. Sickles EA. Successful methods to reduce false-positive mammography interpretations. Radiol Clin North Am. 2000;38(4):693-700. 19. Tobias IS, Baum M. False positive findings of mammography will have psychological consequences [letter]. BMJ. 1996;312(7040):1227. 20. Woloshin S, Schwartz LM. The benefits and harms of mammography screening: understanding the trade-offs. JAMA. 2010;303(2):164-165.
Original Investigation Research
21. Brodersen J, Siersma VD. Long-term psychosocial consequences of false-positive screening mammography. Ann Fam Med. 2013;11(2): 106-115. 22. Bond M, Pavey T, Welch K, et al. Systematic review of the psychological consequences of false-positive screening mammograms. Health Technol Assess. 2013;17(13):1-170, v-vi. 23. Salz T, Richman AR, Brewer NT. Meta-analyses of the effect of false-positive mammograms on generic and specific psychosocial outcomes. Psychooncology. 2010;19(10):1026-1034. 24. Gold M, Siegel J, Russell L, et al, eds. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996. 25. Cole EB, Pisano ED, Kistner EO, et al. Diagnostic accuracy of digital mammography in patients with dense breasts who underwent problem-solving mammography: effects of image processing and lesion type. Radiology. 2003;226(1):153-160. 26. Hendrick RE, Lewin JM, D'Orsi C, et al. Non-inferiority study of ffdm in an enriched diagnostic cohort: comparison with screen-film mammography in 625 women. In: Yaffe M, ed. International Workshop on Digital Mammography 2000: 5th International Workshop on Digital Mammography. Madison, WI: Medical Physics; 2001:475-481. 27. Lewin JM, D’Orsi CJ, Hendrick RE, et al. Clinical comparison of full-field digital mammography and screen-film mammography for detection of breast cancer. AJR Am J Roentgenol. 2002;179(3):671-677. 28. Skaane P, Skjennald A. Screen-film mammography versus full-field digital mammography with soft-copy reading: randomized trial in a population-based screening program—the Oslo II Study. Radiology. 2004;232(1):197-204. 29. Skaane P, Young K, Skjennald A. Population-based mammography screening: comparison of screen-film and full-field digital mammography with soft-copy reading—Oslo I study. Radiology. 2003;229(3):877-884.
digital mammographic imaging screening trial: objectives and methodology. Radiology. 2005;236 (2):404-412. 31. Tosteson AN, Stout NK, Fryback DG, et al; DMIST Investigators. Cost-effectiveness of digital mammography breast cancer screening. Ann Intern Med. 2008;148(1):1-10. 32. Pisano ED, Gatsonis C, Hendrick E, et al; Digital Mammographic Imaging Screening Trial (DMIST) Investigators Group. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353(17):1773-1783. 33. Pisano ED, Hendrick RE, Yaffe MJ, et al; DMIST Investigators Group. Diagnostic accuracy of digital versus film mammography: exploratory analysis of selected population subgroups in DMIST. Radiology. 2008;246(2):376-383. 34. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983. 35. Marteau TM, Bekker H. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(pt 3):301-306. 36. Kind P. The EuroQol instrument: an index of health-related quality of life. In: Spilker B, ed. Quality of Life and Pharmacoeconomics in Clinical Trials. 2nd ed. Philadelphia, PA: Lippincott-Raven; 1996. 37. Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Med Care. 2005; 43(3):203-220. 38. Swan JS, Fryback DG, Lawrence WF, Sainfort F, Hagenauer ME, Heisey DM. A time-tradeoff method for cost-effectiveness models applied to radiology. Med Decis Making. 2000;20(1):79-88. 39. Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291(1):71-78.
30. Pisano ED, Gatsonis CA, Yaffe MJ, et al. American College of Radiology Imaging Network
Invited Commentary
Are the Harms of False-Positive Screening Test Results Minimal or Meaningful? Kurt Kroenke, MD
That most screening test results will be normal or negative is commonplace, but the reality that abnormal results are frequently false-positive is not always well appreciated, nor is it fully conveyed to patients. How does a patient feel after Related article page 954 a false-positive test result? Tosteson and colleagues1 concluded from their longitudinal study that “false-positive mammograms are associated with a measurable, small, and transient effect on personal anxiety.” However, a closer look at all jamainternalmedicine.com
the outcomes assessed in this well-done study reveal some adverse consequences that, although not serious, may nonetheless be meaningful. The authors chose as their primary outcomes a 6-item version of the Spielberger State-Trait Anxiety Inventory (STAI-6) and the 5-item EuroQol instrument (EQ-5D). The STAI-6 is a general rather than disease-specific measure of anxiety, and research has shown that questions directed at specific cancer fears or test-related worries are more sensitive in detecting patient distress after mammography with false-positive results.2 JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 06/03/2015
961
Research Original Investigation
Effects of False-Positive Screening Mammograms
The EQ-5D assesses 5 items, 4 of which would not be expected to be sensitive to test results (mobility, self-care, pain, and general activities). The single item assessing mood asks respondents whether they are not, moderately, or extremely anxious or depressed. It is therefore not surprising that the STAI-6 showed only a small effect of false-positive mammograms on increased anxiety, which was not sustained at 1-year follow-up, and the EQ-5D showed no effect. The study findings regarding more specific test-related concerns, however, do not seem trivial. The proportion of women reporting at least moderate anxiety was 50.6% in those with a false-positive mammogram compared with only 15.7% of women with a negative mammogram. If moderate or greater anxiety is considered a meaningful harm, this is an absolute risk increase of 34.9%, yielding a number needed to harm of 2.9. In addition, more women with false-positive mammograms (35.2% vs 15.4%) reported at least moderate discomfort associated with additional care after their mammogram. As expected, the proportions of women with false-positive mammograms who required additional imaging (66.2% vs 4.5% for women with negative mammograms) or any biopsy (14.6% vs 1.1%) were also substantially higher. The understandable aversion toward a false-positive result was further supported by the fact that most women (81.6%) would choose a more uncomfortable mammographic technique that had fewer false positives and would travel up to 4 hours for such a test. Are these psychological, physical, and economic costs of falsepositive mammograms minimal or meaningful? These adverse consequences would be less concerning if false-positive mammograms were an uncommon event. However, the cumulative probability of a woman receiving at least one false-positive mammogram within 10 years is 61.3% with annual and 41.6% with biennial screening.3 The cumulative probability of biopsy recommendations based on a falsepositive mammogram is 7.0% with annual and 4.8% with biennial screening. This increase in likelihood of a falsepositive mammogram over the screening life span of a woman amplifies the adverse consequences at a population level. Although the authors considered the psychological consequences “transient,” they did not reassess patients until 1 year later. Moreover, when cancer-specific fears and testrelated worries are examined rather than generic anxiety, a recent meta-analysis suggested the presence of persistent distress for up to 3 years.2 Although the consequences of false-positive screening have been studied most extensively for breast cancer, a few studies have also suggested adverse consequences of screening for cervical, prostate, colon, and lung cancer.4-6 My focus on the potential harms of false-positive mammograms is not to detract from the numerous strengths of the important study by Tosteson and colleagues,1 including its longitudinal nature, 1-year follow-up, participant sampling strategy, high participation rates, and appropriate analyses. In par-
ARTICLE INFORMATION Author Affiliations: Center for Health Information and Communication, Health Services Research & Development, US Department of Veterans Affairs, 962
ticular, the authors deserve credit for examining many relevant outcomes. Nor is my intent to devalue periodic mammography, which is one of only several evidence-based screening tests for cancer. We must simply acknowledge that diagnostic tests, like medications, can have adverse effects. There are several ways of dealing with the reality of falsepositive mammograms. First, improved communication with patients about the risks and benefits of a screening test and shared decision making are important steps, but they are not currently feasible in the 10 to 20 minutes allotted for primary care visits. For example, it has been estimated that just to carry out the health care maintenance interventions recommended by the US Preventive Services Task Force for a panel of patients would take a physician close to 8 hours daily (because the average patient has nearly 25 such recommendations), leaving scant time for addressing acute concerns or chronic disease management.7 Thus, whether patient communication is done through effective and engaging educational materials or by other members of the health care team needs to be worked out. Moreover, prompt communication after a positive mammogram about what an abnormal result signifies is desirable, as is expedited workup. Second, universal screening in younger age groups (40-49 years) regardless of risk status should continue to be evaluated. European countries have been less insistent about promoting mammography in these age groups. Third, compared with annual screening, biennial screening reduces the cumulative probability of false-positive results without substantially reducing the detection of incident cancers. Fourth, access to available prior mammograms by radiologists cuts the false-positive rate in half.3 Finally, the development of screening tests that are more specific (ie, have fewer false positives) with a minimal decrement in sensitivity would also reduce the harms. Although digital mammography is rapidly supplanting film-screen mammography, its specificity is not higher.3 Few screening tests have been studied as rigorously as mammography. Although it clearly identifies tumors that cannot be palpated, a recent study8 raises the possibility that mammography leads to overdiagnosis of breast cancer. The investigators reported long-term mortality rates in 89 835 women aged 40 to 59 years who were randomized to yearly mammography vs breast examinations during a 5-year period. Although more tumors were detected in the mammography arm during the screening period, there was no difference in 25year breast cancer or overall mortality rates. Given the controversy concerning the risks and benefits of mammography, it is critical to enhance patients’ understanding of screening, to engage patients in shared decision making, and to communicate and reconcile abnormal results in a patient-centered and efficient fashion. This approach will benefit not only patients undergoing mammography but also those undergoing the many other screening procedures fundamental to clinical practice.
Indianapolis, Indiana; Regenstrief Institute, Inc, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis.
Corresponding Author: Kurt Kroenke, MD, Regenstrief Institute, Inc, 1050 Wishard Blvd, Fifth Floor, Indianapolis, IN 46202 (kkroenke @regenstrief.org).
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 06/03/2015
jamainternalmedicine.com
Effects of False-Positive Screening Mammograms
Published Online: April 21, 2014. doi:10.1001/jamainternmed.2014.160. Conflict of Interest Disclosures: None reported. REFERENCES 1. Tosteson ANA, Fryback DG, Hammond CS, et al. Consequences of false-positive screening mammograms [published online April 21, 2014]. JAMA Intern Med. doi:10.1001 /jamainternmed.2014.981. 2. Bond M, Pavey T, Welch K, et al. Psychological consequences of false-positive screening mammograms in the UK. Evid Based Med. 2013;18 (2):54-61.
jamainternalmedicine.com
Original Investigation Research
3. Hubbard RA, Kerlikowske K, Flowers CI, Yankaskas BC, Zhu W, Miglioretti DL. Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 2011;155(8):481-492. 4. Brewer NT, Salz T, Lillie SE. Systematic review: the long-term effects of false-positive mammograms. Ann Intern Med. 2007;146(7):502-510. 5. McNaughton-Collins M, Fowler FJ Jr, Caubet JF, et al. Psychological effects of a suspicious prostate cancer screening test followed by a benign biopsy result. Am J Med. 2004;117(10):719-725.
6. Harris RP, Sheridan SL, Lewis CL, et al. The harms of screening: a proposed taxonomy and application to lung cancer screening. JAMA Intern Med. 2014;174(2):281-285. 7. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635-641. 8. Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014;348:g366. doi:10.1136/bmj.g366.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 06/03/2015
963
breast screening result groups five months after their last breast screening appointment. J Public Health Med. 1998;20(4):396-403. 10. Brett J, Bankhead C, Henderson B, Watson E, Austoker J. The psychological impact of mammographic screening: a systematic review. Psychooncology. 2005;14(11):917-938. 11. Brewer NT, Salz T, Lillie SE. Systematic review: the long-term effects of false-positive mammograms. Ann Intern Med. 2007;146(7):502510. 12. Brodersen J, Thorsen H, Cockburn J. The adequacy of measurement of short and long-term consequences of false-positive screening mammography. J Med Screen. 2004;11(1):39-44. 13. Burman ML, Taplin SH, Herta DF, Elmore JG. Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization. Ann Intern Med. 1999;131(1):1-6. 14. Castells X, Molins E, Macià F. Cumulative false positive recall rate and association with participant related factors in a population based breast cancer screening programme. J Epidemiol Community Health. 2006;60(4):316-321. 15. Christiansen CL, Wang F, Barton MB, et al. Predicting the cumulative risk of false-positive mammograms. J Natl Cancer Inst. 2000;92(20): 1657-1666. 16. Currence BV, Pisano ED, Earp JA, et al. Does biopsy, aspiration or six-month follow-up of a false-positive mammogram reduce future screening or have large psychosocial effects? Acad Radiol. 2003;10(11):1257-1266. 17. Sickles EA. False positive rate of screening mammography. N Engl J Med. 1998;339(8):561-562, author reply 563. 18. Sickles EA. Successful methods to reduce false-positive mammography interpretations. Radiol Clin North Am. 2000;38(4):693-700. 19. Tobias IS, Baum M. False positive findings of mammography will have psychological consequences [letter]. BMJ. 1996;312(7040):1227. 20. Woloshin S, Schwartz LM. The benefits and harms of mammography screening: understanding the trade-offs. JAMA. 2010;303(2):164-165.
Original Investigation Research
21. Brodersen J, Siersma VD. Long-term psychosocial consequences of false-positive screening mammography. Ann Fam Med. 2013;11(2): 106-115. 22. Bond M, Pavey T, Welch K, et al. Systematic review of the psychological consequences of false-positive screening mammograms. Health Technol Assess. 2013;17(13):1-170, v-vi. 23. Salz T, Richman AR, Brewer NT. Meta-analyses of the effect of false-positive mammograms on generic and specific psychosocial outcomes. Psychooncology. 2010;19(10):1026-1034. 24. Gold M, Siegel J, Russell L, et al, eds. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996. 25. Cole EB, Pisano ED, Kistner EO, et al. Diagnostic accuracy of digital mammography in patients with dense breasts who underwent problem-solving mammography: effects of image processing and lesion type. Radiology. 2003;226(1):153-160. 26. Hendrick RE, Lewin JM, D'Orsi C, et al. Non-inferiority study of ffdm in an enriched diagnostic cohort: comparison with screen-film mammography in 625 women. In: Yaffe M, ed. International Workshop on Digital Mammography 2000: 5th International Workshop on Digital Mammography. Madison, WI: Medical Physics; 2001:475-481. 27. Lewin JM, D’Orsi CJ, Hendrick RE, et al. Clinical comparison of full-field digital mammography and screen-film mammography for detection of breast cancer. AJR Am J Roentgenol. 2002;179(3):671-677. 28. Skaane P, Skjennald A. Screen-film mammography versus full-field digital mammography with soft-copy reading: randomized trial in a population-based screening program—the Oslo II Study. Radiology. 2004;232(1):197-204. 29. Skaane P, Young K, Skjennald A. Population-based mammography screening: comparison of screen-film and full-field digital mammography with soft-copy reading—Oslo I study. Radiology. 2003;229(3):877-884.
digital mammographic imaging screening trial: objectives and methodology. Radiology. 2005;236 (2):404-412. 31. Tosteson AN, Stout NK, Fryback DG, et al; DMIST Investigators. Cost-effectiveness of digital mammography breast cancer screening. Ann Intern Med. 2008;148(1):1-10. 32. Pisano ED, Gatsonis C, Hendrick E, et al; Digital Mammographic Imaging Screening Trial (DMIST) Investigators Group. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353(17):1773-1783. 33. Pisano ED, Hendrick RE, Yaffe MJ, et al; DMIST Investigators Group. Diagnostic accuracy of digital versus film mammography: exploratory analysis of selected population subgroups in DMIST. Radiology. 2008;246(2):376-383. 34. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983. 35. Marteau TM, Bekker H. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(pt 3):301-306. 36. Kind P. The EuroQol instrument: an index of health-related quality of life. In: Spilker B, ed. Quality of Life and Pharmacoeconomics in Clinical Trials. 2nd ed. Philadelphia, PA: Lippincott-Raven; 1996. 37. Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Med Care. 2005; 43(3):203-220. 38. Swan JS, Fryback DG, Lawrence WF, Sainfort F, Hagenauer ME, Heisey DM. A time-tradeoff method for cost-effectiveness models applied to radiology. Med Decis Making. 2000;20(1):79-88. 39. Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291(1):71-78.
30. Pisano ED, Gatsonis CA, Yaffe MJ, et al. American College of Radiology Imaging Network
Invited Commentary
Are the Harms of False-Positive Screening Test Results Minimal or Meaningful? Kurt Kroenke, MD
That most screening test results will be normal or negative is commonplace, but the reality that abnormal results are frequently false-positive is not always well appreciated, nor is it fully conveyed to patients. How does a patient feel after Related article page 954 a false-positive test result? Tosteson and colleagues1 concluded from their longitudinal study that “false-positive mammograms are associated with a measurable, small, and transient effect on personal anxiety.” However, a closer look at all jamainternalmedicine.com
the outcomes assessed in this well-done study reveal some adverse consequences that, although not serious, may nonetheless be meaningful. The authors chose as their primary outcomes a 6-item version of the Spielberger State-Trait Anxiety Inventory (STAI-6) and the 5-item EuroQol instrument (EQ-5D). The STAI-6 is a general rather than disease-specific measure of anxiety, and research has shown that questions directed at specific cancer fears or test-related worries are more sensitive in detecting patient distress after mammography with false-positive results.2 JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 06/03/2015
961
Research Original Investigation
Effects of False-Positive Screening Mammograms
The EQ-5D assesses 5 items, 4 of which would not be expected to be sensitive to test results (mobility, self-care, pain, and general activities). The single item assessing mood asks respondents whether they are not, moderately, or extremely anxious or depressed. It is therefore not surprising that the STAI-6 showed only a small effect of false-positive mammograms on increased anxiety, which was not sustained at 1-year follow-up, and the EQ-5D showed no effect. The study findings regarding more specific test-related concerns, however, do not seem trivial. The proportion of women reporting at least moderate anxiety was 50.6% in those with a false-positive mammogram compared with only 15.7% of women with a negative mammogram. If moderate or greater anxiety is considered a meaningful harm, this is an absolute risk increase of 34.9%, yielding a number needed to harm of 2.9. In addition, more women with false-positive mammograms (35.2% vs 15.4%) reported at least moderate discomfort associated with additional care after their mammogram. As expected, the proportions of women with false-positive mammograms who required additional imaging (66.2% vs 4.5% for women with negative mammograms) or any biopsy (14.6% vs 1.1%) were also substantially higher. The understandable aversion toward a false-positive result was further supported by the fact that most women (81.6%) would choose a more uncomfortable mammographic technique that had fewer false positives and would travel up to 4 hours for such a test. Are these psychological, physical, and economic costs of falsepositive mammograms minimal or meaningful? These adverse consequences would be less concerning if false-positive mammograms were an uncommon event. However, the cumulative probability of a woman receiving at least one false-positive mammogram within 10 years is 61.3% with annual and 41.6% with biennial screening.3 The cumulative probability of biopsy recommendations based on a falsepositive mammogram is 7.0% with annual and 4.8% with biennial screening. This increase in likelihood of a falsepositive mammogram over the screening life span of a woman amplifies the adverse consequences at a population level. Although the authors considered the psychological consequences “transient,” they did not reassess patients until 1 year later. Moreover, when cancer-specific fears and testrelated worries are examined rather than generic anxiety, a recent meta-analysis suggested the presence of persistent distress for up to 3 years.2 Although the consequences of false-positive screening have been studied most extensively for breast cancer, a few studies have also suggested adverse consequences of screening for cervical, prostate, colon, and lung cancer.4-6 My focus on the potential harms of false-positive mammograms is not to detract from the numerous strengths of the important study by Tosteson and colleagues,1 including its longitudinal nature, 1-year follow-up, participant sampling strategy, high participation rates, and appropriate analyses. In par-
ARTICLE INFORMATION Author Affiliations: Center for Health Information and Communication, Health Services Research & Development, US Department of Veterans Affairs, 962
ticular, the authors deserve credit for examining many relevant outcomes. Nor is my intent to devalue periodic mammography, which is one of only several evidence-based screening tests for cancer. We must simply acknowledge that diagnostic tests, like medications, can have adverse effects. There are several ways of dealing with the reality of falsepositive mammograms. First, improved communication with patients about the risks and benefits of a screening test and shared decision making are important steps, but they are not currently feasible in the 10 to 20 minutes allotted for primary care visits. For example, it has been estimated that just to carry out the health care maintenance interventions recommended by the US Preventive Services Task Force for a panel of patients would take a physician close to 8 hours daily (because the average patient has nearly 25 such recommendations), leaving scant time for addressing acute concerns or chronic disease management.7 Thus, whether patient communication is done through effective and engaging educational materials or by other members of the health care team needs to be worked out. Moreover, prompt communication after a positive mammogram about what an abnormal result signifies is desirable, as is expedited workup. Second, universal screening in younger age groups (40-49 years) regardless of risk status should continue to be evaluated. European countries have been less insistent about promoting mammography in these age groups. Third, compared with annual screening, biennial screening reduces the cumulative probability of false-positive results without substantially reducing the detection of incident cancers. Fourth, access to available prior mammograms by radiologists cuts the false-positive rate in half.3 Finally, the development of screening tests that are more specific (ie, have fewer false positives) with a minimal decrement in sensitivity would also reduce the harms. Although digital mammography is rapidly supplanting film-screen mammography, its specificity is not higher.3 Few screening tests have been studied as rigorously as mammography. Although it clearly identifies tumors that cannot be palpated, a recent study8 raises the possibility that mammography leads to overdiagnosis of breast cancer. The investigators reported long-term mortality rates in 89 835 women aged 40 to 59 years who were randomized to yearly mammography vs breast examinations during a 5-year period. Although more tumors were detected in the mammography arm during the screening period, there was no difference in 25year breast cancer or overall mortality rates. Given the controversy concerning the risks and benefits of mammography, it is critical to enhance patients’ understanding of screening, to engage patients in shared decision making, and to communicate and reconcile abnormal results in a patient-centered and efficient fashion. This approach will benefit not only patients undergoing mammography but also those undergoing the many other screening procedures fundamental to clinical practice.
Indianapolis, Indiana; Regenstrief Institute, Inc, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis.
Corresponding Author: Kurt Kroenke, MD, Regenstrief Institute, Inc, 1050 Wishard Blvd, Fifth Floor, Indianapolis, IN 46202 (kkroenke @regenstrief.org).
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 06/03/2015
jamainternalmedicine.com
Effects of False-Positive Screening Mammograms
Published Online: April 21, 2014. doi:10.1001/jamainternmed.2014.160. Conflict of Interest Disclosures: None reported. REFERENCES 1. Tosteson ANA, Fryback DG, Hammond CS, et al. Consequences of false-positive screening mammograms [published online April 21, 2014]. JAMA Intern Med. doi:10.1001 /jamainternmed.2014.981. 2. Bond M, Pavey T, Welch K, et al. Psychological consequences of false-positive screening mammograms in the UK. Evid Based Med. 2013;18 (2):54-61.
jamainternalmedicine.com
Original Investigation Research
3. Hubbard RA, Kerlikowske K, Flowers CI, Yankaskas BC, Zhu W, Miglioretti DL. Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 2011;155(8):481-492. 4. Brewer NT, Salz T, Lillie SE. Systematic review: the long-term effects of false-positive mammograms. Ann Intern Med. 2007;146(7):502-510. 5. McNaughton-Collins M, Fowler FJ Jr, Caubet JF, et al. Psychological effects of a suspicious prostate cancer screening test followed by a benign biopsy result. Am J Med. 2004;117(10):719-725.
6. Harris RP, Sheridan SL, Lewis CL, et al. The harms of screening: a proposed taxonomy and application to lung cancer screening. JAMA Intern Med. 2014;174(2):281-285. 7. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635-641. 8. Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014;348:g366. doi:10.1136/bmj.g366.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 06/03/2015
963
