Likelihood of additional work-up among women undergoing routine screening mammography: the impact of age, breast density, and hormone therapy use.
ABSTRACT Mammography screening can involve subsequent work-up to determine a final screening outcome. Understanding the likelihood of different events that follow initial screening is important if women and their health care providers are to be accurately informed about the screening process.
We conducted an analysis of additional work-up following screening mammography to characterize use of supplemental imaging and recommendations for biopsy and/or surgical consultation and the factors associated with their use. We included all events following screening mammography performed between 1/1/1998 and 12/31/1999 on a population-based sample of 37,632 New Hampshire women. We calculated adjusted odds ratios (OR) and 95% confidence intervals (CI) for supplemental imaging and recommended biopsy and/or surgical consultation as function of age, menopausal status and HRT use, breast density, and family history of breast cancer.
Ninety-one percent of women (n = 34,445) did not require supplemental imaging. Among those who did (n = 3187), 84% had additional views, 9% ultrasound, and 7% received both. Supplemental imaging was affected by age (OR 0.84; 95% CI = 0.76-0.94 for 50-59; OR = 0.66; 95% CI = 0.58-0.75 for > or = 60 versus < 50), menopausal status, and HRT use (OR = 1.33; 95% CI = 1.21-1.47 for peri- or post-menopausal HRT users; OR = 1.14; 95% CI = 1.01-1.29 for premenopausal versus peri- or post-menopausal non-HRT users), breast density (OR = 1.43; 95% CI = 1.33-1.55 for dense versus fatty breasts) and family history (OR = 1.15; 95% CI = 1.06-1.25 for any versus none). In women with supplemental imaging, age (OR = 1.80; 95% CI = 1.11-2.90 for > or = 60, relative to <50) and imaging type (OR = 3.23; 95% CI = 2.38-4.38 for ultrasound with or without additional views versus additional views only) were significantly associated with biopsy and/or surgical consultation recommendation. In those with no supplemental imaging, breast density was associated with recommended biopsy and/or surgical consultation (OR = 1.53; 95% CI = 1.13-2.07 for dense versus fatty breasts).
Breast density and HRT use are both independent predictors of use of supplemental imaging in women. With advancing age (age 60 and older), women were less likely to require follow-up imaging but more likely to receive a recommendation for biopsy and/or surgical consultation. This information should be used to inform women about the likelihood of services received as part of the screening work-up.
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ABSTRACT: A few studies have observed reduced breast cancer mortality in women who used hormone therapy before diagnosis. Due to the high prevalence of past and current hormone use, it is important to investigate whether these preparations are related to breast cancer mortality. To evaluate the influence of prediagnostic use of hormone therapy on breast cancer mortality, a prospective cohort of 12,269 women ages 50 years or more diagnosed with incident invasive breast cancer and residents of Wisconsin, Massachusetts, or New Hampshire were enrolled in three phases beginning in 1988. They were followed for death until December 31, 2005, using the National Death Index. Cumulative mortality and multivariable adjusted hazard rate ratios for breast cancer and other mortality causes were calculated for women according to any hormone therapy use, and for exclusive use of estrogen or estrogen-progestin (EP). During an average 10.3 years of follow-up, 1,690 deaths from breast cancer were documented. Cumulative mortality from breast cancer was lower among hormone therapy users, specifically current users at the time of diagnosis, and EP users, compared with nonusers. Adjusted survival varied by type and duration of hormone therapy before diagnosis. A reduced risk of death from breast cancer was associated with EP preparations (hazard rate ratio, 0.73; 0.59-0.91) and with > or =5 years of EP use (0.60; 0.43-0.84). No association was observed for women who were former or current users of E-alone preparations. Although use of combined EP preparations increases breast cancer risk, in this study, use of these hormones before diagnosis was associated with reduced risk of death after a breast cancer diagnosis. The better survival among users, particularly of EP, persisted after adjustment of screening, stage, and measured confounders.Cancer Epidemiology Biomarkers & Prevention 05/2008; 17(4):864-71. · 4.12 Impact Factor
Article: Feasibility and satisfaction with a tailored web-based audit intervention for recalibrating radiologists' thresholds for conducting additional work-up.[show abstract] [hide abstract]
ABSTRACT: To examine the feasibility of and satisfaction with a tailored web-based intervention designed to decrease radiologists' recommendation of inappropriate additional work-up after a screening mammogram. We developed a web-based educational intervention designed to reduce inappropriate recall. Radiologists were randomly assigned to participate in an early intervention group or a late (control) intervention group, the latter of which served as a control for a 9-month follow-up period, after which they were invited to participate in the intervention. Intervention content was derived from our prior research and included three modules: 1) an introduction to audit statistics for mammography performance; 2) a review of data showing radiologists' inflated perceptions of medical malpractice risks related to breast imaging, and 3) a review of data on breast cancer risk among women seen in their practices. Embedded within the intervention were individualized audit data for each participating radiologists obtained from the national Breast Cancer Surveillance Consortium. Seventy-four radiologists (37.8%; 74/196) consented to the intervention, which was completed by 67.5% (27/40) of those randomized to the early intervention group and 41.2% (14/34) of those randomized to the late (control) group. Thus, a total of 41 (55%) completed the intervention. On average, three log-ins were used to complete the program (range 1-14), which took approximately 1 hour. Ninety-five percent found the program moderately to very helpful in understanding how to calculate basic performance measures. Ninety-three percent found viewing their own performance measures moderately to very helpful, and 83% reported it being moderately to very important to learn that the breast cancer risk in their screening population program was lower than perceived. The percentage of radiologists who reported that the risk of medical malpractice influences their recall rates dropped from 36.3% preintervention to 17.8% after intervention with a similar drop in perceived influence of malpractice risk on their recommendations for breast biopsy (36.4 to 17.3%). More than 75% of radiologists answered the postintervention knowledge questions correctly, and the percent of time spent in breast imaging did not appear to influence responses. The majority (>92%) of participants correctly responded that the target recall rate in the United States is 9%. The mean self-reported recall rates were 13.0 for radiologists spending <40% time in breast imaging and 14.9% for those spending >40% time spent in breast imaging, which was highly correlated with their actual recall rates (0.991; P < .001). Radiologists who begin an internet-based tailored intervention designed to help reduce unnecessary recall will likely complete it, although only 55% who consented to the study actually undertook the intervention. Participants found the program useful in helping them understand why their recall rates may be elevated.Academic radiology 03/2011; 18(3):369-76. · 2.09 Impact Factor
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ABSTRACT: A review is presented of recent advances in optical imaging and spectroscopy and the use of light for addressing breast cancer issues. Spectroscopic techniques offer the means to characterize tissue components and obtain functional information in real time. Three-dimensional optical imaging of the breast using various illumination and signal collection schemes in combination with image reconstruction algorithms may provide a new tool for cancer detection and treatment monitoring.Journal of Mammary Gland Biology and Neoplasia 05/2006; 11(2):165-81. · 6.74 Impact Factor