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PubMed1998

Predictors of mammography use among women veterans.

We examined mammography use patterns of women veterans and explored Veterans Administration (VA) health care use and military experience as predictors of mammography use by this population. We conducted a national telephone survey of women veterans. A sample of 397 women veterans was selected from all military discharges from 1971 through 1994. A 3 x 2 stratification scheme was used: three age groups (35-49, 50-64, > or = 65 years old) and two VA user groups indicating whether (VA user) or not (VA nonuser) they received any health care from a VA Medical Center in the last 5 years. The response rate was 75% (297 of 397). Analyses included bivariate techniques and weighted logistic regression. We found that women veterans told to have a mammogram by a health care professional were more than five times more likely to have ever had a mammogram (OR 5.41, CI 4.63-6.32) and nearly twice as likely to have had a mammogram within the past 2 years (OR 1.81, CI 1.57-2.09) as those who were not told to do so, controlling for age, race, VA user status, and length of military service. Regular VA users were more likely to have had a mammogram ever and within the past 2 years, controlling for other factors. Mammography use was not necessarily at a VA medical center. Interventions that promote better provider-patient communication and target older women veterans may have the most potential benefit. Whether VA health care is filling an important gap in access to mammography for older women veterans is an important policy question and warrants further research.

Adult↗
PubMed2004

A cost-effectiveness comparison of three tailored interventions to increase mammography screening.

BACKGROUND: Mammography is the primary method used for breast cancer screening. However, adherence to recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of three combinations of tailored telephone and mailed intervention strategies for increasing adherence to mammography. METHODS: There were 1044 participants who were randomly assigned to one of four groups. A logistic regression model with adherence as the dependent variable and group as the independent variable was used to test for significant differences, and a ratio of cost/improvement in mammogram adherence evaluated the cost-effectiveness. RESULTS: All three of the interventions (tailored telephone, tailored mail, and tailored telephone and mail) had significantly better adherence rates compared with the control group (usual care). However, when also considering costs, one emerged as the superior strategy. The cost-effectiveness ratios for the three interventions show that the tailored mail (letter) was the most cost-effective strategy, achieving 43.3% mammography adherence at a marginal cost of dollar 0.39 per 1% increase in women screened. The tailored mail plus telephone achieved greater adherence (49.4%), but at a higher cost (dollar 0.56 per 1% increase in women screened). CONCLUSIONS: A tailored mail reminder is an effective and economical intervention to increase mammography adherence. Future research should confirm this finding and address its applicability to practice in other settings.

Adult↗
PubMed2003

Validation of self-reported screening mammography histories among women with and without breast cancer.

As part of a case-control study of the efficacy of screening mammography, the authors validated the mammography histories of 2,495 women aged 40-64 years with incident breast cancer diagnosed in 1994-1998 and a 25% random sample of 615 controls never diagnosed with breast cancer, all reporting a mammogram in the past 5 years. Subjects from five metropolitan areas of the United States were cross-classified by facility records ("gold standard") and self-report according to history of a recent screening mammogram (within 1 year or within 2 years). Sensitivity and specificity of self-reported screening at 1 year were 0.93 and 0.82, respectively, for cases and 0.92 and 0.80 for controls. At 2 years, sensitivity and specificity were 0.97 and 0.78 for both cases and controls. Confidence intervals for the differences in sensitivity and specificity were narrow and included zero. Scant evidence was found of telescoping (recollection of events as more recent than actual). Findings suggest that, in an interview-based case-control study of the efficacy of screening mammography, 1) estimated true prevalences of recent screening mammography adjusted for sensitivity and specificity will be slightly lower than self-reported prevalences, and 2) differential misclassification of exposure status is slight. Therefore, odds ratios will likely be biased toward the null, underestimating screening efficacy.

Adult↗
PubMed2004

Intervention to increase screening mammography among women 65 and older.

This paper reports the results of a practice-based intervention program to increase mammography screening among women 65 and older who receive their health care in the private sector. Forty-three primary-care practices and 2147 women in central and western North Carolina were enrolled in the study, and 1911 women completed all phases of the study. The intervention was a three-stage educational and counseling program designed to become progressively more intensive at each stage. The interventions included provider education in the form of current information on issues in mammography for older women, simply written educational materials on breast cancer and screening mailed to women, and a brief telephone counseling session for the women. While the analysis revealed no overall effect across all three stages of the intervention program, tests for interaction indicated a significant program effect for women who were 80 or older, had less than 9 years of education, were black, or had no private insurance to supplement Medicare. The results suggested that providing primary-care physicians with information on screening older women and providing the women with useful educational materials can increase participation in screening mammography among subgroups of women currently least likely to receive mammography screening.

Aged↗
PubMed2003

Women's perception of the benefits of mammography screening: population-based survey in four countries.

BACKGROUND: Screening programmes are often actively promoted to achieve high coverage, which may result in unrealistic expectations. We examined women's understanding of the likely benefits of mammography screening. METHODS: Telephone survey of random samples of the female population aged > or =15 years in the US, UK, Italy, and Switzerland using three closed questions on the expected benefits of mammography screening. RESULTS: A total of 5964 women were contacted and 4140 women (69%) participated. Misconceptions were widespread: a majority of women believed that screening prevents or reduces the risk of contracting breast cancer (68%), that screening at least halves breast cancer mortality (62%), and that 10 years of regular screening will prevent 10 or more breast cancer deaths per 1000 women (75%). In multivariate analysis higher number of correct answers was positively associated with higher educational status (odds ratio [OR] = 1.44, 95% CI: 1.25, 1.66) and negatively with having had a mammography in the last 2 years (OR = 0.86, 95% CI: 0.73, 1.01). Compared with US women (reference group) and Swiss women (OR = 0.98, 95% CI: 0.82, 1.18) respondents in Italy (OR = 0.61, 95% CI: 0.50, 0.74) and the UK (OR = 0.73, 95% CI: 0.60, 0.88) gave fewer correct answers. CONCLUSION: In the US and three European countries a high proportion of women overestimated the benefits that can be expected from screening mammography. This finding raises doubts on informed consent procedures within breast cancer screening programmes.

Adolescent↗
PubMed1996

Effect of estrogen replacement therapy on the specificity and sensitivity of screening mammography.

BACKGROUND: Previous studies have demonstrated that mammographic breast density increases following the initiation of estrogen replacement therapy (ERT). The effect, if any, that this increase in density has on the specificity (related to false-positive readings) and the sensitivity (related to false-negative readings) of screening mammography is unknown. PURPOSE: Using a retrospective cohort study design, we assessed the effects of ERT on the specificity and the sensitivity of screening mammography. METHODS: Participants (n = 8779) were postmenopausal women, aged 50 years or older, who were enrolled in a health maintenance organization located in western Washington state and who entered a breast cancer screening program between January 1988 and June 1993. Two-view mammography was performed as part of a comprehensive breast cancer screening visit. Menopausal status, as well as demographic and risk-factor information, was recorded via self-administered questionnaires. Hormonal replacement therapy type and use were determined from questionnaire data and from an automated review of pharmacy records. Individuals diagnosed with breast cancer within 12 months of their first screening-program mammograms were identified through use of a regional cancer registry. Risk ratios (RRs) plus 95% confidence intervals (CIs) of false-positive as well as false-negative examinations among current and former ERT users (with never users as the reference group) were calculated. Reported P values are two-sided. RESULTS: The specificity of mammographic screening was lower for current users of ERT than for never users or former users. Defining a positive mammographic reading as any non-normal reading (either suspicious for cancer or indeterminate), the adjusted RR (95% CI) of a false-positive reading for current users versus never users was 1.33 (1.15-1.54) (P < .001); for former users versus never users, the RR (95% CI) was 1.00 (0.87-1.15). The adjusted mammographic specificities (95% CIs) for never users, former users, and current users of ERT were 86% (84%-88%), 86% (84%-87%), and 82% (80%-84%), respectively. Defining a positive reading more rigorously (i.e., as suspicious for cancer only), the adjusted RRs (95% CIs) of false-positive readings for current users and former users (versus never users) were 1.71 (1.37-2.14) (P < .001) and 1.16 (0.93-1.45), respectively. Sensitivity was also lower in women currently receiving ERT. The unadjusted RR (95% CI) of a false-negative reading for current users versus never users was 5.23 (1.09-25.02) (P = .04); for former users versus never users, the RR (95% CI) was 1.06 (0.10-10.87). The unadjusted mammographic sensitivities (95% CI) for never users, former users, and current users of ERT were 94% (80%-99%), 94% (69%-99%), and 69% (38%-91%), respectively. CONCLUSIONS AND IMPLICATIONS: Current use of ERT is associated with lower specificity and lower sensitivity of screening mammography. Lower specificity could increase the cost of breast cancer screening, and lower sensitivity may decrease its effectiveness.

Aged↗
PubMed1998

Scintimammographic analysis of nonpalpable breast lesions previously identified by conventional mammography.

BACKGROUND: In randomized trials, screening mammography has led to decreased mortality from breast cancer. However, the low positive predictive value of mammography (i.e., the proportion of patients with a positive test result who actually have breast cancer) results in a large number of unnecessary biopsies. We determined whether scintimammography with technetium-99m-sestamibi is a useful supplemental diagnostic tool for women with nonpalpable breast abnormalities identified by conventional mammography. METHODS: Scintimammography was performed preoperatively on 70 women who were 31-66 years of age (mean age and median age = 51 years). These women had nonpalpable breast abnormalities identified by conventional mammography; subsequently, a needle-localization excisional biopsy of each suspicious lesion was performed. Scintimammographic images were interpreted independently by two nuclear medicine physicians who were blinded to all clinical and pathologic data, and an interobserver variation analysis was performed. RESULTS: Interobserver variation analysis of the scintimammographic findings showed an agreement for breast diagnosis of 97% and a kappa coefficient of 0.90. Comparison of scintimammographic findings and histopathologic results revealed that the sensitivity (proportion of patients with breast cancer who had a positive test result), the specificity (proportion of patients without breast cancer who had a negative test result), the positive predictive value and the negative predictive value (proportion of patients with a negative test result who actually did not have breast cancer) of scintimammography were 56% (95% confidence interval [CI] = 23%-85%), 87% (95% CI = 75%-94%), 38% (95% CI = 15%-68%), and 93% (95% CI = 82%-98%), respectively. Four of nine breast cancers were not detected by scintimammography. CONCLUSION: Because of excellent interobserver agreement, scintimammography provides an objective way of detecting primary breast carcinoma. In view of its low sensitivity and positive predictive value, however, scintimammography is not currently recommended as a screening test in patients with nonpalpable positive mammographic findings.

Adult↗
PubMed1997

Benefit of screening mammography in women aged 40-49: a new meta-analysis of randomized controlled trials.

Eight randomized controlled trials (RCTs) of screening mammography have been conducted involving women aged 40-49 at entry. Current data are now available from these trials at 10.5 to 18 years of follow-up (average follow-up time: 12.7 years). Meta-analysis has been performed using a Mantel-Haenszel estimator method to combine current follow-up data from the eight RCTs of mammography that included women aged 40-49 at entry, including new follow-up data presented at the NIH Consensus Development Conference held January 21-23, 1997. Combining the most recent follow-up data on women aged 40-49 at entry into all eight RCTs yields a statistically significant 18% mortality reduction among women invited to screening mammography (relative risk: 0.82; 95% confidence interval: 0.71-0.95). Combining all current follow-up data on women aged 40-49 at entry into the five Swedish RCTs yields a statistically significantly 29% mortality reduction among women invited to screening (relative risk: 0.71; 95% confidence interval: 0.57-0.89). Meta-analysis including the most recent follow-up data from all eight RCTs involving women aged 40-49 at entry demonstrates for the first time a statistically significant mortality reduction due to regular screening mammography in women of this age group.

Adult↗
PubMed2005

Late-stage breast cancer among women with recent negative screening mammography: do clinical encounters offer opportunity for earlier detection?

BACKGROUND: Opportunities to prevent late-stage breast cancer within the course of usual care are needed. We evaluate whether clinical encounters offer such opportunities. METHODS: Within seven health care plans, we identified 1298 women aged more than 50 years with early (<3 cm), late-stage (> or = 3 cm), or metastatic invasive breast cancer diagnosed during 1995-1999, whose first screening mammogram 13-36 months prior to the diagnosis (index) was negative. We audited all care occurring in the health plans up to 36 months prior to the cancer diagnoses. Ordinal logistic regression compared the frequency of events by disease category. We hypothesized that during the 13-36 months prior to diagnosis, women with late-stage or metastatic breast cancer would have more symptoms and be more likely to have breast-related clinical visits but have less breast screening (clinical breast examination [CBE] or mammography) than women with early-stage disease, thereby indicating clinical opportunities for earlier detection. RESULTS: We found no differences in demographic characteristics across breast cancer stage among the 1298 women. Both before and after the negative index mammogram but during the 13-36 months prior to diagnosis, few women had breast symptoms (5% before index, 8% after), but many sought breast care (86% before index, 90% after) and screening CBE (62% before index, 43% after). Only the occurrence of screening CBE (odds ratio [OR] = 0.73, 95% confidence interval [CI] = 0.56 to 0.95) or screening mammograms (OR = 0.74, 95% CI = 0.57 to 0.97) after the negative index mammogram reduced odds of more severe disease at diagnosis. CONCLUSION: Although the mortality benefit of CBE, or one compared to two year mammography has not been established, we found that women with late-stage breast cancers undetected by screening mammography did not experience opportunities for earlier detection except through CBE or additional screening mammography.

Aged↗
PubMed1992

How much of the recent rise in breast cancer incidence can be explained by increases in mammography utilization? A dynamic population model approach.

Largely unexplained increases in breast cancer incidence of about 1% per year have been documented back to the 1940s. Since 1982, breast cancer incidence in women aged 40 years and above has been increasing at a faster rate than this long-term secular trend, especially in women aged 60 years and above. Increases in the use of mammography since 1982 (which have been documented in population surveys of women) provide the most plausible explanation for the incidence increase over the long-term secular trend. A study by White et al. (J Natl Cancer Inst 1990;82:1546-52) found that, for women aged 45-64 years, the increase in mammography utilization could explain the incidence increase, while for women aged 65-74 years, it could account for only half the increase. The authors have developed an alternative model to that of White et al. that incorporates estimates of differential lead time (time from screen detection to clinical detection in the absence of screening) by age group. Using this model, the authors show that if older women have longer lead times, than similar increases in mammography utilization across age groups will lead to a larger incidence increase in older women. Thus, the observed increases in mammography utilization are generally concordant with increases in incidence, even in the older age groups.

Adult↗
PubMed2003

A special ionisation chamber for quality control of diagnostic and mammography X ray equipment.

A quality control program for X ray equipment used for conventional radiography and mammography requires the constancy check of the beam qualities in terms of the half-value layers. In this work, a special double-faced parallel-plate ionisation chamber was developed with inner electrodes of different materials, in a tandem system. Its application will be in quality control programs of diagnostic and mammography X ray equipment for confirmation of half-value layers previously determined by the conventional method. Moreover, the chamber also may be utilised for measurements of air kerma values (and air kerma rates) in X radiation fields used for conventional radiography and mammography. The chamber was studied in relation to the characteristics of saturation, ion collection efficiency, polarity effects, leakage current, and short-term stability. The energy dependence in response of each of the two faces of the chamber was determined over the conventional radiography and mammography X ray ranges (unattenuated beams). The different energy response of the two faces of the chamber allowed the formation of a tandem system useful for the constancy check of beam qualities.

Equipment Design↗
PubMed2005

Optimisation of X-ray examinations in Lithuania: start of implementation in mammography.

Optimisation of medical X-ray examinations is very important for the enhancement of the reliability of the examination and for the reduction of the radiation dose to patients. Results of investigations of doses to patients during mammography using thermoluminescence dosemeters at different hospitals are presented together with a brief overview of the situation for mammography in Lithuania. It is shown that the entrance surface air kerma varies in a broad range and differed from hospital to hospital. Nevertheless the calculated values of average glandular dose (AGD) for a 'standard' breast being relatively high were comparable with those (3.2 mGy per exposure at net optical density 1.4) currently accepted by international authorities. Differences in AGD values evaluated at different hospitals demonstrate the existing potential for optimisation of the mammography screening procedures. The results of this investigation will be included in a database for patient doses in Lithuania and used for establishing a national reference dose level for mammography. Currently, reference levels recommended by international authorities are used in Lithuania.

Adult↗
PubMed2005

A high-resolution voxel phantom of the breast for dose calculations in mammography.

Though mammography is one of the most sensitive methods to detect breast cancer, the benefit of the mammography screening programmes is still not clearly proven. One of the reasons is the radiation dose delivered by the examinations. Simulations of the radiation transport based on realistic breast phantoms are a useful tool to estimate the dose for the risk relevant parenchymal tissue. Specimens of real breasts have been fixated using a specially designed process while being compressed as in mammography. They have been scanned using the high-resolution mode of a CT. A segmentation has been carried out by assigning the voxels to different tissues. The resulting voxel phantom allows the assessment of tissue doses by Monte-Carlo calculations and can be used to simulate the diagnostic outcome of different imaging procedures. Three different tissues were separated: skin, adipose and 'breast tissue'. This allows reasonable calculations of the average glandular doses in mammography.

Adipose Tissue↗
PubMed1990

The role of mammography in detecting breast cancer in augmented breasts.

Recent reports suggest that mammographic findings may be compromised in patients who have undergone augmentation mammoplasty. Therefore, early detection of breast cancer by mammography may be obscured. We reviewed records for our patients with breast cancer after augmentation mammoplasty to define further the role and accuracy of mammography. Six patients aged 34 to 52 years (mean, 42 years) had a diagnosis of breast carcinoma 4 to 14 years (mean, 7.2 years) after augmentation mammoplasty. Five patients had preoperative mammographic examinations. Suspicious lesions were seen in 4 patients, and microcalcifications were identified in the fifth. The sixth patient had a normal xeromammogram. Pathological diagnosis was infiltrating ductal carcinoma in 5 patients and intraductal carcinoma in 1. Findings for lymph nodes were negative in 3 patients; 2 others had positive findings in one lymph node, and 1 had positive results in four lymph nodes. Five patients had a suspicious mass that was palpated on self-examination or by the patient's plastic surgeon, and the sixth patient had a routine screening mammogram. Two of 3 patients with positive lymph nodes received adjuvant chemotherapy. This report confirms the role of mammography as a screening tool in making the diagnosis of breast cancer in women who have undergone augmentation mammoplasty. The importance of self-examination and follow-up by the plastic surgeon is stressed. The data suggest that mammography remains an accurate method for detecting breast lesions.

Adult↗
PubMed1997

Predicting mammography and breast self-examination in African American women.

Breast cancer mortality is significantly greater in African American women than in their Caucasian counterparts. The purpose of this study was to identify variables associated with the breast cancer screening behaviors of mammography utilization and breast self-examination (BSE) in a convenience sample of low income African American women. A total of 328 African American women, living in a large midwestern metropolitan area, who were at < or = 150% of poverty level, and between the ages of 45 and 64 years were included in this study. Data were collected over a period of 18 months. Predisposing, enabling, and need variables from Anderson's theoretical framework included perceived susceptibility, benefits, barriers, confidence, knowledge, physician recommendation, demographic characteristics, and past experiences, as well as health-care and insurance information. Variables that significantly predicted mammography utilization included perceived barriers, mammography suggested by health-care professionals, recent thoughts about mammography, and a regular medical doctor. Variables that significantly predicted either frequency or proficiency of BSE included susceptibility, benefits, confidence, knowledge, barriers, and a regular physician. Implications for clinical practice include (a) recognizing predictors of screening among low-income African American women; (b) addressing culturally specific barriers, e.g., cancer fatalism, in order to increase compliance with screening; (c) establishing consistency in primary care providers; and (d) increasing confidence and knowledge through education.

Black or African American↗
PubMed1988

A comparison of digitized storage phosphors and conventional mammography in the detection of malignant microcalcifications.

The detectability of malignant tumor-derived microcalcifications with conventional mammography was compared to that with digital images (2000 X 2510 pixels by 10 bits) derived from a storage phosphor-based digital radiography system capable of 5 line pair/mm resolution at identical exposure factors (30 kVp, 250 mAs, 65 cm film-focus distance). Microcalcifications (50-800 microns in diameter) were randomly superimposed on a preserved human breast specimen. ROC analysis based on 480 observations made by four readers indicated that the ability to detect the calcifications with digital images (ROC area = 0.871 +/- 0.066) was equivalent to conventional mammography (ROC area = 0.866 +/- 0.075) despite lower spatial resolution. With digital mammography, 62% of all clusters were correctly localized, but only 23.6% of the individual calcifications were counted. With conventional mammography 61% of all clusters were correctly localized, but significantly more of the individual calcifications (31.5%) were counted.

Breast Diseases↗
PubMed1990

Comparison of breast consistency at palpation with breast density at mammography.

Palpable breast consistency on physical examination was compared with the breast density on mammography for 909 consecutive patients. One of two experienced nurse practitioners palpated each patient's breasts and assigned a consistency value of 1 (little palpable breast consistency) to 4 (maximal palpable breast consistency). Seven mammographers rated the breast density on mammography as either fatty, mild, moderate, or marked parenchymal density for each breast. A low statistical correlation between the two parameters was shown. Thirty-seven percent of markedly dense breasts on mammography was rated only 1 or 2 on palpation. Thus, breast consistency judged by palpation cannot be directly correlated with the density shown on mammography and cannot be used to predict optimal radiographic technique.

Adult↗
PubMed1993

Spatial resolution in digital mammography.

RATIONAL AND OBJECTIVES: Digital acquisition systems currently available limit spatial resolution in digital mammography to roughly 0.1 mm/pixel. The objective of this study is to determine if high-quality mammography is possible at this resolution. METHODS: The influence of spatial resolution on diagnostic quality was investigated by comparing observer performance on film to that on digitized film. A 0.1-mm sampling distance was used for digitization. Detection of mammographic details was studied by measuring threshold contrast as a function of detail size for small circular objects in the range of 0.12 to 2.5 mm. Characterization of microcalcifications was investigated in a receiver operating characteristic (ROC) study, in which 10 radiologists read 72 mammographic details with microcalcifications, both digitally and on film. RESULTS: Digitization improved the detectability of the larger, low contrast objects, whereas for small objects the detectability did not change. The authors found that even under the most optimal circumstances, isolated spherical calcifications with diameters smaller than 0.13 mm are not detectable with film-screen mammography, despite its resolution limit of 15 line patterns per mm (lp/mm). The ability to characterize microcalcification clusters did not change significantly with digitization. However, the results suggest that differentiation of benign from malignant cases decreases slightly, and that characterization of different types of malignancies somewhat improves by digitization. Mean differences between the two modalities were considerably smaller than the interobserver variability. CONCLUSION: A relatively low spatial resolution of 0.1 mm/pixel does not prohibit high-quality diagnostic performance in digital mammography.

Breast Diseases↗