Burden for Patients After Unclear Mammogram Results
One of every seven women who undergo annual mammography screening for breast cancer will be called back for follow-up tests.
These women can worry for days or weeks that the “suspicious” finding the radiologist has seen on their mammogram will be cancer. They might also incur direct and indirect medical costs.
A supplement to the September issue of the Journal of Women’s Health highlights the burden, both financial and personal, of screening recall, and outlines some of the newer technologies for imaging the breast that could improve the accuracy of screening and make it more cost efficient.
“Our goal in breast cancer screening is to find the most cancers at the lowest cost,” Susan C. Harvey, MD, from Johns Hopkins Medical Institutions in Baltimore, told Medscape Medical News. “We want to up our value.”
In one study, the burden of direct and indirect costs borne by recalled patients after a false-positive screening mammogram was evaluated by Matthew Alcusky, PharmD, from the Jefferson School of Population Health in Philadelphia, and colleagues.
They identified 1,723,139 patients 40 to 75 years of age who underwent screening mammography but were not diagnosed with breast cancer. Of these, 259,028 (15%) were recalled for additional diagnostic procedures.
Most of the women (54.6%) were 50 to 64 years of age; 41.5% were 40 to 49 years. Women in the younger age group were more likely to be recalled than those in the older age group (17.9% vs 13.0%).
The team found that the recall rate varied by geographic location, with the largest recall rates in the Northeast (21.2%) and Mid-Atlantic (19.7%), and the lowest rates in the West (13.1%) and Midwest (13.4%).
In addition, patients residing in rural areas were recalled less often than patients in nonrural areas (12.8% vs 15.4%).
The most common procedure used for recall examination was diagnostic mammography, which was used 80% of the time. Ultrasound was used for 66% of recall exams, and computer-aided detection was used 40% of the time.
The most expensive unnecessary procedure, image-guided biopsy, was used in 11% of cases, and was the largest driver of total patient costs (mean, $351). This was followed by diagnostic mammography ($50) and ultrasound ($58).
Overall, the cost to the patient associated with recall after a false-positive screening mammogram was $138 for all recalled women and $449 for women who underwent a biopsy.
More than a quarter of recalled patients did not incur any direct costs, reflecting the large variability in health coverage plans.
“There is not a lot known about the indirect costs to patients from inconclusive screening exams.”
“There is a lot written about breast cancer screening, but there is not a lot known about the indirect costs to patients from inconclusive screening exams,” Dr. Harvey said.
In addition to monetary costs, there are psychosocial costs that affect women. The problem is compounded by “tremendous” variation in the guidelines and recommendations for screening, “which are confusing both to women and the referring physicians. My opinion is that we need to look at new approaches to breast cancer screening,” she explained.
An example of such an approach is 3D mammography, or breast tomosynthesis. The US Food and Drug Administration has approved the technology, and Dr. Harvey said she believes that it provides the best screening for many women.
3D mammography obtains multiple adjacent images that are reconstructed into 1 mm slices that can be reviewed on a computer, as detailed by her team in their report on newer technologies for breast imaging.
“This has allowed us both to decrease the false alarms or recall rate and to increase the number of cancers that we can identify, so the technology has great value,” Dr. Harvey said, adding, “this is my opinion, but it is also supported by the literature.”
3D mammography is also the best technology currently available for screening women with dense breasts, who make up about 40% of women.
“Cancers are harder to see in dense breast tissue, and what does show on standard mammography can often mimic cancer, so 3D benefits those women,” she explained.
Supplementing mammography with ultrasound can increase the accuracy of cancer detection, but also results in more unnecessary biopsies, Dr. Harvey said.
“We did the ACRIN 6666 trial here at Hopkins (JAMA. 2012;307:1394-1404). It was looking at high-risk women who had heterogeneously dense or dense breast tissue, and we supplemented their mammogram with whole-breast ultrasound. We found a statistically significant increase in accuracy in cancer detection, but we also found that we ended up doing biopsies on many more women. So far, when we look at 3D mammography, it looks like it’s going to detect about three in 1000 more cancers than 2D alone, but with fewer recall rates,” she said.
Women Still Uninformed About Screening
In an editorial published in the supplement, Dr. Harvey decries the lack of understanding on the part of many women about breast cancer screening.
“Here at Hopkins, we have tried to educate women about screening recommendations, new legislation, breast density issues, risk factors, and new technologies, and we’re still not effective,” she writes.
“Breast imaging is heavily regulated by the federal government. We are required to provide results in writing of all imaging and to send out letters to remind women when their screening exam is due. In our practice, when we send out these letters, we also send educational information about breast density, screening mammography, and ultrasound, and it is very clear that women don’t read that. We have even tried evening seminars for education and patient feedback, but women don’t like to come in the evening, so we don’t know the answer. It’s a real challenge,” Dr. Harvey explained.
The media can also confuse the issue, she said.
“For instance, the New York Times has published some conflicting articles about breast cancer,” Dr. Harvey noted. One article by Gina Kolata indicated that some breast cancers just go away, whereas another article noted that women are dying in Uganda because they are not getting screened.
Not long after the publication of her article, Kolata came to Hopkins as an invited speaker. “One of the questions she was asked was whether she saw her job as education or entertainment. She said entertainment,” Dr. Harvey reported. “We struggle with information that gets put out in the media because many women perceive it as education and the media are thinking of it as entertainment. This adds to the confusion.”
“Who likes to have a mammogram? If you read an article on the front page of the New York Times that tells you that you don’t need it, of course you are going to say, ‘great, I’ll cancel my appointment, I don’t want to go’,” she noted.
J Womens Health (Larchmt). 2014;23 Suppl 1:S1-S2, S3-S9, S11-S19.