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Self-referred mammography patients: analysis of patients' characteristics.

Among mammography patients, a small but growing group of highly motivated women refer themselves directly for screening without the suggestion of their physicians. We surveyed 485 patients during a 3-month period to study how self-referred mammography patients differ from physician-referred patients. Self-referred patients were more likely than physician-referred patients to have a family income of more than $30,000 per year, to be college graduates, and to consider their health as good or excellent. A large percentage of self-referred patients performed other health-promoting practices, but were not significantly more likely to do these than were physician-referred patients. Women who referred themselves were more likely to have a friend with breast cancer and to believe that cancer could be cured. They expressed much less worry about radiation exposure and were more likely to consider $50.00 an appropriate charge for a screening mammogram. By far, the greatest motivator for self-referred patients was health promotion and disease prevention. Self-referred mammography patients tend to be wealthier, more education, and less concerned about the cost and radiation dose of mammography when compared with physician-referred mammography patients.

Attitude to Health↗

Economic issues in screening mammography.

The issues surrounding screening mammography present apparent conflicts: conflicting guidelines for screening; an oversupply of facilities, yet inadequate access to mammography for some groups of women; increased medicolegal vulnerability as participation in screening is promoted; disparate results from studies of cost-effectiveness; wide variations in delivery modes and practice patterns of facilities, yet an evolution toward a single set price for mammography by payers for screening. This review does not claim to offer solutions to these conflicts, rather it attempts to carry forward a discussion of the issues. With these conflicts, screening mammography may be only a microcosm of similar economic issues in general health care delivery. Our health care system has room for variety, if access and quality are improved at an affordable cost. Screening for breast cancer with mammography will not reach its full potential to reduce mortality until many of these issues can be resolved.

Cost-Benefit Analysis↗

Mammography in women with axillary lymphadenopathy and normal breasts on physical examination: value in detecting occult breast carcinoma.

OBJECTIVE: The purpose of this study was to determine the value of mammography in detecting occult carcinoma in patients with axillary adenopathy and normal breasts on physical examination. MATERIALS AND METHODS: We analyzed the results of mammography performed in 17 patients; all women had palpable axillary lymphadenopathy of unknown origin and all had normal breasts on physical examination. RESULTS: In 10 of the 17 patients, mammographic findings were abnormal. The mammographic finding of axillary adenopathy in seven patients was inconsequential because the nodes were evident on physical examination. Three patients had abnormal mammographic findings that were potentially significant, including one with a poorly defined mass suggestive of breast carcinoma, one with a subcutaneous nodule, and one with parenchymal breast edema. Two of 17 patients had an occult breast cancer. In only one of the patients was the cancer detected on mammography. The other patient had undergone prior left mastectomy and was thought to have metastases to the right axilla from the contralateral breast. Mammographic findings in this latter patient were normal. CONCLUSION: While occult breast carcinoma was relatively common in our series (two of 17 patients), the ability to detect the tumor with mammography was disappointing (one of two patients). This may be explained by the fact that one postmastectomy patient with occult carcinoma had metastatic disease to the contralateral axilla and a normal remaining breast, which was pathologically confirmed at mastectomy. Our experience suggests that mammography is valuable in patients with normal breasts on physical examination who have primary carcinoma involving ipsilateral axillary lymph nodes. The procedure should be included in the diagnostic evaluation of patients with axillary adenopathy in order to detect the unusual case of occult breast carcinoma.

Axilla↗

Use of digital mammography in needle localization procedures.

OBJECTIVE: With digital technology, images can be displayed rapidly and manipulated. This study was undertaken to assess the duration and accuracy of needle localizations performed with digital vs film-screen technology. These two technologies also were compared with respect to radiation doses and ability to image a standard phantom. SUBJECTS AND METHODS: A prototype digital mammographic system with both a 512 x 512 matrix and a 1024 x 1024 matrix was evaluated by using the American College of Radiology mammography accreditation phantom, and these results were compared with testing done on commercially available, dedicated, analog mammography equipment. Duration, accuracy of needle placement, and number of exposures needed to perform localization were recorded for 157 consecutive needle localizations done with digital technology, and these results were compared with data collected from 103 needle localizations done with film-screen technology. Another 33 localizations attempted with digital imaging were aborted because of technical factors. Average glandular doses were calculated for those women who had a compressed breast thickness of 4-5 cm. RESULTS: The time to complete needle localization was reduced by almost 50%, from 20 to 11 min, when digital technology was used. Because of the small (5 x 5 cm) field of view of the digital system, an additional mammogram obtained at the onset of the procedure was found to be helpful in localization, but otherwise the number of images was the same regardless of imaging receptor. Mean glandular dose was reduced by about 50% with digital imaging from 0.219 to 0.120 cGy. In those 17% (33/190) of needle localizations that could not be completed with digital imaging, failure was due to a variety of factors. Despite improved detectability of fibrils, specks, and masses on digital images, digital systems did not show some fine calcifications or soft-tissue masses during needle localizations. Difficulty in imaging lesions near the chest wall or in the axilla and the small field of view also caused procedures attempted with digital imaging to be aborted and completed with film-screen systems. CONCLUSION: The time to complete needle localization was reduced by 50%, with a similar reduction in patients' radiation dose, when digital mammography was used. These findings should be applicable to stereotaxic procedures done with digital mammography. Factors limiting the use of digital mammography equipment included inability to image some fine calcifications and some masses, difficulty in imaging near the chest wall and in the axilla, and a small field of view.

Breast Neoplasms↗

Interval breast cancers in the Screening Mammography Program of British Columbia: analysis and classification.

OBJECTIVE: Interval cancers in an annual mammography screening program are defined as cancers detected within 12 months after a mammographic screening in which findings are considered normal. Our objective was to analyze interval cancers for histologic type, tumor size, staging, and histologic grade. A classification for interval cancers is presented. Detection of interval cancers is an integral part of quality control and is required for the establishment of sensitivity rates for screening mammography, a necessary part of implementing the recommendations for breast cancer screening. MATERIALS AND METHODS: A total of 47,583 mammographic screening examinations of 38,219 women were available for review for the period of July 1988 to March 1991. Linkage with the provincial population-based cancer registry provided identification of all interval cancers of the breast. Histologic analysis of breast cancers was provided by an internationally recognized breast cancer pathologist who interpreted the specimens twice. RESULTS: A total of 207 breast cancers were detected at mammographic screening (true-positive cancers) during the first 33 months of the program, and 37 interval cancers were identified during the 33 months of screening plus a 12-month interval. Blinded review by three radiologists experienced in screening mammography resulted in classification of 21 of 37 cases as true interval cancers and 16 cases as misses. No interval cancers were missed because of poor mammographic technique. The sensitivity of screening mammography was 85%, 63% for patients less than 50 years old and 89% for patients more than 50 years old. The specificity was 93% for all patients (both younger and older than 50 years). CONCLUSION: The availability of a population-based cancer registry in the province of British Columbia makes an accurate determination of interval cancers and sensitivity rates possible. These data are essential for quality analysis, program planning, and education of radiologists in screening mammography. There were more true interval cancers than misses, and histologic analysis demonstrated that the majority of interval cancers were in stages I and II.

Adult↗

The New Hampshire Mammography Network: the development and design of a population-based registry.

OBJECTIVE: Some authors have proposed a national mammography registry to improve and monitor breast diagnostic practices. However, issues such as confidentiality, accuracy, and direct and indirect costs are practical barriers to implementing such a registry. This paper describes the development and design of a population-based mammography registry in New Hampshire. The project's objectives are to assess the accuracy of mammography by comparing interpretive results with pathology and tumor-registry reports and to improve mammographic performance by reporting findings to facilities, radiologists, and pathologists statewide. MATERIALS AND METHODS: We recruited radiologists and pathologists through professional associations and facilities through site visits. Data used to develop and design the registry were collected during site visits, using structured face-to-face interview methods. Only one site refused to provide site-specific information. RESULTS: Facilities in New Hampshire estimated the annual mammographic volume to be approximately 148,000. We have noted a great deal of variability in mammography practices. Their principal methods for determining screening versus diagnostic mammograms were by patient self-reports (44% of practices), referring physicians' reports (38%), and radiologists' reports (18%). Although 71% of practices have computers, only 16% have radiology information systems or hospital information systems that offer computerized patient-tracking capabilities. More than 90% of New Hampshire radiologists exclusively use freehand dictation for reporting, and although almost 50% codify reports, only 11% use the American College of Radiology lexicon. These data and concerns expressed by radiologists, pathologists, technologists, and administrators helped shape the New Hampshire registry. CONCLUSION: Heterogeneity of radiologic practices poses major challenges for implementing a population-based mammography registry. Issues such as confidentiality, the difficulty of assessing diagnostic acumen, and the time involved in providing data to a registry must be adequately addressed. For the registry to succeed in such diverse settings, researchers, radiologists, pathologists, technologists, and administrative staff must collaborate and cooperate.

Adult↗

Fixed-facility workplace screening mammography.

OBJECTIVE: Potential barriers to compliance with screening mammography guidelines include the cost and inconvenience involved with undergoing the procedure. Workplace screening with mobile mammography is one possible approach to the convenience barrier. However, fixed-facility workplace screening is a viable alternative for any company with a large workforce in one location. This paper describes our initial experience with one such fixed facility. MATERIALS AND METHODS: The facility was a cooperative venture by a large pharmaceutical company and an academic radiology department to provide convenient, no-cost (to the patient) screening mammography to employees, dependents, and retirees more than 40 years old. The pharmaceutical company built the facility within its corporate headquarters and the academic radiology department provided the equipment and personnel. The company was billed a fixed cost per examination. RESULTS: In the first 22 months of operation, 4210 (of 4559 scheduled) screening mammograms were obtained. The mean age of the population was 53 years old. Ninety percent of the screening mammograms were interpreted as negative or benign; 10% required additional workup. Of the screened population, 62 biopsies were recommended and 60 were performed. Of these, 42 were benign and 18 malignant. The cancer detection rate was 4.3 per 1000 (0.43%). At the time of diagnosis, six patients were stage 0, 10 patients were stage I, one patient was stage II, and one patient was stage III. Eleven of the 18 patients had minimal cancers. Of the patients who completed a satisfaction survey, 97% percent expressed a high degree of satisfaction with the screening process and stated they would use the facility in the future. CONCLUSION: A fixed facility for workplace screening mammography is a viable way to provide nearly barrier-free access to high-quality mammography. Patient acceptance is high.

Breast Neoplasms↗

Mammography in the evaluation of nipple inversion.

OBJECTIVE: The purpose of this study was to correlate the clinical and mammographic appearances of the nipple, determine the effects of breast compression on nipple position, and describe the mammographic findings in women with nipple inversion. SUBJECTS AND METHODS: We examined 312 consecutive women who were referred for mammography using routine craniocaudal and mediolateral oblique views, which resulted in 595 breasts imaged Nipple position (normal or inverted) was assessed visually, both with and without breast compression, and correlated with the findings at mammography. RESULTS: Of the 312 women, 29 (9%) had visually inverted nipples without breast compression; similarly, of the 595 breasts, 36 (6%) had visually inverted nipples without breast compression. Clinical nipple inversion was chronic in 33 (92%) of 36 breasts and acute in the remaining three breasts (8%) Nipple inversion occurred at birth in one (3%) of 36 breasts, during puberty in 21 (58%), and during adulthood in 14 (39%). Reported causative factors were pregnancy in one (3%) of 36 breasts, nursing in one (3%), prior benign biopsy in one (3%), and prior cancer in one (3%). In the other 32 breasts (89%), causative factors were not known. Both visually and mammographically, 29 (81%) of 36 clinically inverted nipples remained inverted with breast compression, but seven (19%) became normal in position. Of the 312 women, 23 (7%) had inverted nipples on mammography; likewise, of the 595 breasts, 29 nipples (5%) were inverted on mammography. Mammographic findings in the 33 breasts with chronically inverted nipples were normal in 29 (88%), probably benign masses in two (6%), multiple cysts in one (3%), and axillary lymphadenopathy in one (3%). Mammographic findings in the three breasts with acutely inverted nipples were normal in two (67%) and revealed a suspicious mass in one (33%). CONCLUSION: Mammography often failed to reveal nipple inversion; nearly one in five clinically inverted nipples became normal in position as a result of breast compression. In the vast majority of women with nipple inversion, the process was long-standing and without causative factors. Also, these women typically lacked mammographic findings suggestive of malignancy. Of the 14 patients with nipple inversion that had occurred during adulthood, two women (14%) had an underlying malignancy.

Aged↗

Short-interval follow-up mammography versus immediate core biopsy of benign breast lesions: assessment of patient stress.

OBJECTIVE: The stress experienced by women undergoing surveillance mammography for benign lesions was compared with that experienced by women undergoing core biopsy of benign lesions. MATERIALS AND METHODS: A retrospective survey was mailed to women in whom were diagnosed breast abnormalities that were likely to be benign and that were stable at short-interval follow-up mammography (n = 174) or in whom a core biopsy of the breast was performed, with benign findings (n = 116). The survey included questions about stress related to the diagnostic experience as well as questions about who advised the women of the results of their breast imaging studies and about the information provided. RESULTS: Eighty eligible surveys were received from the women who underwent short-interval follow-up mammography, and 58 surveys were received from the women who underwent biopsies. The self-reported overall stress experienced by the women who underwent core biopsies was significantly greater (p < .001) than that reported by the group who were followed up with mammography. The level of anxiety was not affected by the patient's perception of the probability that the lesion represented carcinoma. We found no significant differences in stress between women who discussed their mammogram results with a radiologist and women who were notified by their primary care provider. CONCLUSION: Short-interval follow-up mammography continues to be acceptable for the evaluation of lesions that are probably benign, even when patient anxiety is considered.

Anxiety↗

Outcome analysis for women undergoing annual versus biennial screening mammography: a review of 24,211 examinations.

OBJECTIVE: Our goal was to determine differences in outcome measures between women undergoing annual versus biennial screening mammography. MATERIALS AND METHODS: A retrospective review of prospectively collected data on 24,211 consecutive screening mammography examinations was performed in women aged 40-79 years, all of whom had undergone previous normal screening mammography. Annual screening and biennial screening were defined as examinations performed 10-14 months and 22-26 months, respectively, after previous normal screening mammography. The rates of recall, biopsy, cancer detection, and interval cancer for annual and biennial screening cohorts were calculated, as were tumor size, lymph node status, and stage of invasive cancer. Interval cancer cases were identified by linkage with a regional tumor registry. RESULTS: Of the 4306 biennially screened women, 160 were recalled (3.7%), 45 were biopsied (1.0%), and cancer was detected in 19 (0.44%). Of the 19,905 annually screened women, 518 were recalled (2.6%), 150 were biopsied (0.75%), and cancer was detected in 71 (0.36%). Of the 3278 registry-linked biennially screened women, five had interval cancer (0.15%); of the 15,031 registry-linked annually screened women, 10 had interval cancer (0.07%). For biennial screening-detected cancer and interval invasive cancer combined, the median tumor size was 15 mm, 24% had lymph node metastasis, and 29% were stage 2 or higher. For annual screening-detected cancer, these measures were 11 mm, 14% positive nodes, and 17% stage 2+ cancer, respectively. CONCLUSION: Annual screening mammography results in lower recall rates than does biennial screening (p < .0001). Moreover, annual screening results in the detection of smaller tumors that have a more favorable prognosis (p = .04).

Adult↗

Efficacy of step-oblique mammography for confirmation and localization of densities seen on only one standard mammographic view.

OBJECTIVE: Step-oblique mammography is a technique used to determine with confidence whether a mammographic finding visible on multiple images on only one projection (but not elucidated using standard additional mammographic projections such as the roll view) represents a summation artifact or a true mass, and to precisely localize the true mass for further evaluation (if applicable). This paper describes the step-oblique technique and evaluates its efficacy. MATERIALS AND METHODS: Between January 1, 1993 and December 31, 1998, 69 consecutive women underwent step-oblique mammography for the evaluation of densities seen on multiple images in only one standard projection. Additional images were obtained at 15 degrees stepped increments in obliquity. If a one-projection-only finding was not seen on step-oblique images, the density was judged to represent a summation artifact, completing the examination. If a density was visualized and could be triangulated concordantly on step-oblique images ranging from the craniocaudal to the 90 degrees lateral projection, then it was judged to represent a real lesion. Such a lesion was further characterized (mass, neodensity, architectural distortion, focal asymmetric density) and was localized precisely in three dimensions, permitting imaging-guided tissue diagnosis, if appropriate. For all study patients, we also recorded BI-RADS (American College of Radiology Breast Imaging and Data Reporting System) assessment categories; pathology results for biopsied lesions; and mammographic follow-up, clinical follow-up, and linkage to regional tumor registry for nonbiopsied lesions for which at least 2 years had elapsed since step-oblique mammography. RESULTS: Step-oblique mammography differentiated 50 real lesions from 19 summation artifacts. All 50 real lesions, although initially visible on only one standard projection, were successfully localized in three dimensions. Subsequent management resulted in the prompt detection and diagnosis of seven breast cancers and 21 benign lesions. None of the remaining findings managed by follow-up rather than biopsy have subsequently been found to be malignant. CONCLUSION: Step-oblique mammography is an effective means of evaluating the mammographic finding visible on multiple images on only one standard projection.

Artifacts↗

Medical audit of diagnostic mammography examinations: comparison with screening outcomes obtained concurrently.

OBJECTIVE: We performed a medical audit of our diagnostic mammography practice and compared clinical outcomes with those of screening mammography examinations performed concurrently. MATERIALS AND METHODS: We analyzed 46,857 consecutive mammography examinations (10,007 diagnostic, 36,850 screening) from 1997 to 2000, including data on demographics, image interpretation, and biopsy (including size, nodal status, and cancer stage). RESULTS: The mean age at diagnostic mammography was 55.8 years (mean age at screening mammogram, 59.1 years; p < 0.0001). Among patients who underwent diagnostic examinations, 14.7% had a strong or very strong family history of breast cancer (screening, 11.6%; p < 0.0001). Examination findings were interpreted as abnormal in 14.4% (screening, 5.2%; p < 0.0001). Biopsy was performed in 11.9% (screening, 1.4%; p < 0.0001). Forty-six percent of the biopsies were positive for malignancy (screening, 38%; p < 0.0001). The cancer detection rate was 55 per 1000 (screening, 5/1000; p < 0.0001). Of cancers found, 74.4% were stage 0 or I (screening, 89.3%; p < 0.0001), average size was 18.0 mm (screening, 12.9 mm; p < 0.0001), and axillary nodes were positive for malignancy in 19.9% of invasive cancers (screening, 6.3; p < 0.0001). Differences between diagnostic and screening outcomes were attributable predominantly to the subgroup of diagnostic examinations performed for evaluation of palpable masses. CONCLUSION: Medical auditing of diagnostic mammography examinations yields substantially different results compared with those of screening examinations, including different patient demographics; higher number of positive biopsies; higher cancer detection rates; and larger, more advanced-stage cancers. Diagnostic and screening data should be segregated during auditing, or if this is not possible, analysis of combined results should be based on known differences between diagnostic and screening outcomes.

Breast Neoplasms↗

Interpreting data from audits when screening and diagnostic mammography outcomes are combined.

OBJECTIVE: The objective of this study was to use mathematic models to aid mammography practices in interpreting outcomes data derived from a combination of screening and diagnostic examinations, and in interpreting diagnostic mammography outcomes data that are not segregated by indication for examination. MATERIALS AND METHODS: We analyzed outcomes from 51,805 consecutive mammography examinations. Screening and diagnostic examinations were audited separately. Diagnostic examinations were audited by indication for examination. Extrapolating from our known mix of screening (79%) and diagnostic (21%) examinations, we determined expected combined outcomes for various mixes that might be encountered in clinical practice. Similarly, we determined the expected overall diagnostic mammography outcomes for various clinically relevant mixes of indications for examination. RESULTS: Outcomes vary substantially depending on the mix of screening and diagnostic examinations performed. For example, expected outcomes for practices with screening-diagnostic mixes of 90-10% and 50-50% are, respectively: rate of abnormal findings, 6% versus 11%; rate of positive biopsy findings, 38% versus 42%; cancer detection rate, 10 per 1,000 versus 30 per 1,000; mean invasive cancer size, 14.4 mm versus 16.0 mm; nodal metastasis rate, 8% versus 11%; and rate of stage 0 and stage I cancers, 87% versus 82%. Diagnostic outcomes also vary substantially according to indication for examination, with a higher rate of abnormal findings, a higher rate of positive biopsy findings, and a larger mean invasive cancer size expected for mixes involving a high percentage of workups for palpable lesions. CONCLUSION: When screening and diagnostic mammography outcomes are not segregated during auditing, and when diagnostic outcomes are not segregated by indication for examination, analysis of combined audit data should be based on extrapolations from known outcomes.

Biopsy, Needle↗

Prospective comparison of mammography, sonography, and MRI in patients undergoing neoadjuvant chemotherapy for palpable breast cancer.

OBJECTIVE: The objective of our study was to determine the relative accuracy of mammography, sonography, and MRI in predicting residual tumor after neoadjuvant chemotherapy for breast cancer as compared with the gold standards of physical examination and pathology. SUBJECTS AND METHODS: Forty-one women with stage IIB-III palpable breast cancer were prospectively enrolled in a study investigating the effects of sequential single-agent chemotherapy (doxorubicin followed by paclitaxel or vice versa) on tumor imaging. The study cohort consisted of the first 31 patients (age range, 31-65 years; mean, 45 years) who completed the protocol. All underwent physical examination, mammography, sonography, and MRI before and after receiving each neoadjuvant chemotherapeutic drug. Imaging studies were reviewed by two radiologists using conventional lexicons for lesion analysis, and the findings were compared with clinical response and pathology results. RESULTS: Complete, partial, and stable clinical response as defined by clinical examination was seen in 15, 14, and two of the 31 patients, respectively. Agreement rates about the degree of response were 32%, 48%, and 55%, respectively, for mammography, sonography, and MRI compared with clinical evaluation and did not differ statistically. Agreement about the rate of response as measured by clinical examination, mammography, sonography, and MRI compared with the gold standard (pathology) was 19%, 26%, 35%, and 71%, respectively. Of the four, MRI agreed with the gold standard significantly more often (p < 0.002 for all three paired comparisons with MRI). When there was disagreement with the gold standard, none of the four exhibited a significant tendency to either under- or overestimate. CONCLUSION: MRI appears to provide the best correlation with pathology-better than physical examination, mammography, and sonography-in patients undergoing neoadjuvant chemotherapy. However, MRI may overestimate (6%) or underestimate (23%) residual disease in approximately 29% of the patients (95% confidence interval, 14-48%).

Adult↗

The additional value of US to mammography in the diagnosis of breast cancer. A prospective study.

PURPOSE: To assess the additional value of ultrasonography (US) to mammography in the diagnosis of malignant breast tumors. MATERIAL AND METHODS: Prospectively recorded final assessment categories for mammography and US were compared for 327 (228 palpable and 99 nonpalpable) consecutive malignant tumors confirmed at histology. The additional value of US was assessed for a subpopulation of 71 of these 327 malignancies after excluding mammographically conclusive malignant findings, ductal carcinomas in situ (DCIS), and invasive carcinomas presenting with suspicious microcalcifications, since there is no indication for performing US in these patients. RESULTS: A total of 267 (82%) of the 327 malignant tumors were correctly diagnosed on both imaging modalities. Mammography correctly diagnosed 41 cancers with false-negative US findings as compared with 11 true-positive US diagnoses of malignant tumors with false-negative findings on mammography (McNemar test p<0.001). US correctly diagnosed ("upgraded") 31 (10%) of the 327 malignant tumors with benign or indeterminate mammographic diagnoses. In the subpopulation, US upgraded 20 (42%) of 48 palpable and 10 (44%) of 23 nonpalpable malignant tumors. CONCLUSION: The overall additional value of US to mammography in the diagnosis of breast cancer was rather limited in a population of mixed malignant tumors. Excluding cancers with mammographically conclusive diagnosis and suspicious microcalcifications as well as DCIS from analysis, US correctly upgraded more than 40% of palpable and nonpalpable malignant tumors.

Adult↗

Encouraging attendance at screening mammography: knowledge, attitudes and intentions of general practitioners.

We surveyed a random sample of 200 general practitioners from the Sydney metropolitan area about their attitudes to and knowledge of screening mammography. General practitioners' knowledge about some aspects of screening mammography was found to be limited; only 25% of the sample knew that the risk of breast cancer increases with age and only 30% of the sample knew that the evidence for a reduction in mortality as a result of mammographic screening is weakest for women of less than 50 years of age. Ninety-five per cent of general practitioners were of the opinion that breast self-examination and clinical examination were important for asymptomatic women of more than 45 years of age compared with the 75% of respondents who viewed mammography in the same way. Scores on a scale that was constructed to measure attitudes to mammographic screening showed that 20% of general practitioners had a "very favourable" attitude, and that a further 67% of general practitioners had a "favourable" attitude. No general practitioners had a "very unfavourable" attitude. Eighty-four per cent of general practitioners indicated that they would recommend that their patients attend a free screening-mammography service. Willingness to recommend mammographic screening was predicted by a general practitioner's attitude score. The strongest component of this prediction was a belief that the benefits of screening mammography outweighed the radiation risks. General practitioners need to be supplied with correct information about target groups for screening, so that women in the appropriate age-groups are encouraged to attend screening programmes.

Age Factors↗

Relationship between health status and use of screening mammography and Papanicolaou smears among women older than 70 years of age.

BACKGROUND: Older women whose life expectancy is less than 5 years are unlikely to benefit from screening mammography or Papanicolaou (Pap) smears. Since life expectancy is better predicted by health status than by age alone, guidelines recommend considering an older woman's general health when making screening decisions. OBJECTIVE: To determine whether screening mammography and Pap smears are targeted to healthy older women and are avoided in women with limited life expectancies. DESIGN: Cross-sectional population-based study. SETTING: California. PATIENTS: 4792 women 70 years of age or older who participated in the California Health Interview Survey between November 2000 and October 2001. MEASUREMENTS: Predictor variables included age and health status. Health status was measured by using the Medical Outcomes Study 12-item Short Form Physical Summary Scale. The main outcome was self-reported receipt of screening mammography within the previous 2 years and a screening Pap smear within 3 years. RESULTS: Seventy-eight percent of women reported recent screening mammography, and 77% reported a recent Pap smear. Screening rates decreased with advancing age. However, within each age group, the percentage of women reporting screening did not significantly decrease with worsening health status (P > 0.1 for all comparisons). More than half of women 80 years of age or older in the worst health quartile reported recent screening, representing approximately 81,000 mammograms and 35,000 Pap smears. LIMITATIONS: This study relied on self-report, and the interview response rate was 63.7%. CONCLUSIONS: Rates of recent screening mammography and Pap smears are high among older women in California. Although screening rates drop with advancing age, women in poor health do not avoid screening. Screening should be better targeted to healthy older women and should be avoided in women with limited life expectancies for whom risks of screening outweigh potential benefits.

Aged↗

[Mammography use among 35-50-year-old women. Descriptive study of a population seeking services at the centers of health tests].

OBJECTIVE: The aim of the study was to evaluate mammography rates and indications (diagnosis or screening) among women from 35 to 50 of age, and to search the main factors associated to mammographic screening. DESIGN AND SETTING: The data were collected from 6409 women through a specific questionnaire completed by a nurse. RESULTS: Among women from 35 to 50 years of age, 61% have undergone at least one mammography during their life; 25.6% had undergone a screening mammogram within the last three years. Whatever women's age or indications, the gynecologist was the first physician to prescribe mammography. Logistic regression model adjusting for multiple variables was used to examine factors associated with women who underwent a screening mammography within the last three years. Women more likely to be screened were 45 to 50 years of age (vs 35-40 years of age: adjusted OR 8.9, 95% CI: 7.2 to 11.2), had higher educational level (adjusted OR 1.3, 95% CI: 1.1 to 1.5), had family history of breast cancer (adjusted OR 2.7, 95% CI: 2.1 to 3.4), and used routine gynecologic care (adjusted OR 1.9, 95% CI: 1.6 to 2.4). CONCLUSION: Individual screening by mammography very often occurs after 40 years, Such behaviors may lead public health professionals to question current recommendations for breast cancer mass screening in women 50 years of age and older.

Adult↗