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PubMed2005

The influence of health status, age, and race on screening mammography in elderly women.

BACKGROUND: Screening mammography is controversial for elderly women because of an absence of efficacy data. Decisions to screen are based on individualized assessment of risks and benefits. Our objective was to determine how screening mammography varies by age and race when adjusted for propensity to die. METHODS: In a retrospective cohort study, rates of screening mammogram performed in 2000-2001 based on claims, adjusted for propensity to die in 2000, were determined for a nationally representative 5% random sample of female fee-for-service Medicare beneficiaries 65 years and older in (N = 722,310). RESULTS: The overall rate of screening was 39%. When stratified into quintiles by propensity to die, 2-year rates ranged from 61% in the lowest-risk group to 5% in the highest-risk group. In analyses stratified by age and adjusted for propensity to die, 42% of women aged 65 to 69 years were screened, declining to 26% of women 85 years and older (P<.001). Adjusted screening rates for white women, black women, and women of other races were 40%, 30%, and 25%, respectively (P<.001). Thus, among women with similar health status, the youngest women were 1.61 times more likely to be screened compared with the oldest; compared with black women and women of other races, white women were 1.38 and 1.60 times, respectively, more likely to be screened. CONCLUSIONS: Decisions to screen for breast cancer are related not only to health status but also to age and race. Underuse and overuse of screening mammography likely occurs owing to age- and race-associated decision making. Assessment of life expectancy may more accurately identify women who could benefit from screening.

Age Factors↗
PubMed1986

Mammography of women with suspicious breast lumps.

We analyzed 342 women who had suspicious breast lumps to determine if preoperative mammography could improve the malignancy yield of biopsy procedures. The number of women with cancer of the breast and false-negative mammogram reports ranged from 11% to 25%, depending on how equivocal mammogram reports were interpreted. Therefore, women with clinically suspicious breast lumps should undergo biopsy regardless of mammographic findings. A significant difference in the mean (+/- SD) predictive value of a positive mammogram existed between women above and below the age of 50 years (80 +/- 8 vs 43 +/- 14) because of the age-specific relative prevalence of benign and malignant disease, and because mammography had difficulty distinguishing between benign and malignant lumps (specificity, 70). Preoperative mammography of women with suspicious breast lumps is indicated to screen for occult carcinoma, to prevent biopsy sampling errors, and to judge the adequacy of lumpectomy if the lesion is malignant.

Adult↗
PubMed2003

Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women's Health Initiative Randomized Trial.

CONTEXT: The Women's Health Initiative trial of combined estrogen plus progestin was stopped early when overall health risks, including invasive breast cancer, exceeded benefits. Outstanding issues not previously addressed include characteristics of breast cancers observed among women using hormones and whether diagnosis may be influenced by hormone effects on mammography. OBJECTIVE: To determine the relationship among estrogen plus progestin use, breast cancer characteristics, and mammography recommendations. DESIGN, SETTING, AND PARTICIPANTS: Following a comprehensive breast cancer risk assessment, 16 608 postmenopausal women aged 50 to 79 years with an intact uterus were randomly assigned to receive combined conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo from 1993 to 1998 at 40 clinical centers. Screening mammography and clinical breast examinations were performed at baseline and yearly thereafter. MAIN OUTCOME MEASURES: Breast cancer number and characteristics, and frequency of abnormal mammograms by estrogen plus progestin exposure. RESULTS: In intent-to-treat analyses, estrogen plus progestin increased total (245 vs 185 cases; hazard ratio [HR], 1.24; weighted P<.001) and invasive (199 vs 150 cases; HR, 1.24; weighted P =.003) breast cancers compared with placebo. The invasive breast cancers diagnosed in the estrogen plus progestin group were similar in histology and grade but were larger (mean [SD], 1.7 cm [1.1] vs 1.5 cm [0.9], respectively; P =.04) and were at more advanced stage (regional/metastatic 25.4% vs 16.0%, respectively; P =.04) compared with those diagnosed in the placebo group. After 1 year, the percentage of women with abnormal mammograms was substantially greater in the estrogen plus progestin group (716 [9.4%] of 7656) compared with placebo group (398 [5.4%] of 7310; P<.001), a pattern which continued for the study duration. CONCLUSIONS: Relatively short-term combined estrogen plus progestin use increases incident breast cancers, which are diagnosed at a more advanced stage compared with placebo use, and also substantially increases the percentage of women with abnormal mammograms. These results suggest estrogen plus progestin may stimulate breast cancer growth and hinder breast cancer diagnosis.

Aged↗
PubMed2003

Comparison of screening mammography in the United States and the United kingdom.

CONTEXT: Screening mammography differs between the United States and the United Kingdom; a direct comparison may suggest methods to improve the practice. OBJECTIVE: To compare screening mammography performance between the United States and the United Kingdom among similar-aged women. DESIGN, SETTING, AND PARTICIPANTS: Women aged 50 years or older were identified who underwent 5.5 million mammograms from January 1, 1996, to December 31, 1999, within 3 large-scale mammography registries or screening programs: the Breast Cancer Surveillance Consortium (BCSC, n = 978 591) and National Breast and Cervical Cancer Early Detection Program (NBCCEDP, n = 613 388) in the United States; and the National Health Service Breast Screening Program (NHSBSP, n = 3.94 million) in the United Kingdom. A total of 27 612 women were diagnosed with breast cancer (invasive or ductal carcinoma in situ) within 12 months of screening among the 3 groups. MAIN OUTCOME MEASURES: Recall rates (recommendation for further evaluation including diagnostic imaging, ultrasound, clinical examination, or biopsy) and cancer detection rates were calculated for first and subsequent mammograms, and within 5-year age groups. RESULTS: Recall rates were approximately twice as high in the United States than in the United Kingdom for all age groups; however, cancer rates were similar. Among women aged 50 to 54 years who underwent a first screening mammogram, 14.4% in the BCSC and 12.5% in the NBCCEDP were recalled for further evaluation vs only 7.6% in the NHSBSP. Cancer detection rates per 1000 mammogram screens were 5.8, 5.9, and 6.3, in the BCSC, NBCCEDP, and NHSBSP, respectively. Recall rates were lower for subsequent examinations in all 3 settings but remained twice as high in the United States. A similar percentage of women underwent biopsy in each setting, but rates of percutaneous biopsy were lower and open surgical biopsy higher in the United States. Open surgical biopsies not resulting in a diagnosis of cancer (negative biopsies) were twice as high in the United States than in the United Kingdom. Based on a 10-year period of screening 1000 women aged 50 to 59 years, 477, 433, and 175 women in the BCSC, NBCCEDP, and NHSBSP, respectively, would be recalled; and for women aged 60 to 69 years, 396, 334, and 133 women, respectively. The estimated cancer detection rates per 1000 women aged 50 to 59 years were 24.5, 23.8, and 19.4, respectively, and for women aged 60 to 69 years, 31.5, 26.6, and 27.9, respectively. CONCLUSIONS: Recall and negative open surgical biopsy rates are twice as high in US settings than in the United Kingdom but cancer detection rates are similar. Efforts to improve US mammographic screening should target lowering the recall rate without reducing the cancer detection rate.

Aged↗
PubMed1976

Bilateral breast carcinomas: Role of mammography.

From 1963 to 1973, at Emory Clinic, out of a total of 1112 patients with breast carcinoma studied with mammography, 83 had carcinoma in both breasts. The carcinoma in the second breast was primary in 67 patients and metastatic in 16 patients; in 18 patients there were simultaneous bilateral primary carcinomas. Mammography proved highly effective in detecting the second carcinoma and was reliable in differentiating a second primary from metastatic carcinoma. Forty-one of the second primary carcinomas were not associated with a palpable mass; 31 of these were having mammography as a routine check-up. The second nonsimultaneous carcinoma was considerably smaller than the first and fewer axillary lymph node metastasis. The second primary occurred within 6 years of the first in 86% of the cases with the remaining 14% scattered evenly up to 23 years. At 4 years after the diagnosis of the second primary, 25 of 27 deaths had occurred and only 1 patient was alive with cancer. Breast cancer patients need close follow-up for at least 6 years after the first primary carcinoma; and 4 years past the second primary signals a more optimistic prognosis.

Adult↗
PubMed1977

Conventional mammography, physical examination, thermography and xeroradiography in the detection of breast cancer.

From July 1, 1973, through January 15, 1975, at the Emory University Clinic independent physical examinations, conventional mammography, thermography and xeroradiography of the breast were carried out on 1,003 symptomatic patients by both physicians and radiologic technologists. One year after completion of the study there had been 360 breasts biopsied with 53 malignant and 307 benign lesions demonstrated. Seventy-three percent of the cancers were histologically Stage 0 or Stage I. The detection rate of the cancers by physician and technologist respectively were: 1) conventional mammography 87 and 74%; 2) xeroradiography 65 and 46%; 3) physical examination 62 and 51%; and 4) thermography 29 and 27%. In non-malignant breasts the physician and technologist designated cancer respectively in: 1) thermography 4 and 6%; 2) conventional mammography 6 and 6%; 3) xeroradiography 8 and 10%; and 4) physical examination 11 and 12%.

Adult↗
PubMed1977

Present status of thermography, ultrasound and mammography in breast cancer detection.

Various biophysical methods have been utilized in the diagnosis of breast cancer. To date the best results have been obtained with x-ray mammography. Ultrasound and thermography have great appeal as non-destructive techniques but, in the present state of development, are of limited use. The spatial resolution presently obtainable in ultrasonograms is inadequate for the detection of subclinical cancer and thermography is also of questionable reliability. While an overall true positive rate of 70% to 75% may be anticipated with thermography, the bulk of false negatives would seem to occur in those tumors most amenable to therapy, i.e., subclinical cancers. The "false positive" rate of thermography is also excessive, but would be acceptable for establishing a high risk group if true positive rates could be improved. At present thermography finds its greatest use as an adjunct to mammography and physical examination; it should not be used as the sole modality in a screening program. The efficacy of mammography can be readily demonstrated but the propriety of its use as a screening device has been questioned. This is primarily related to the possible carcinogenic effect of radiation at diagnostic levels. Although the carcinogenic effect is unproven, the dose in radiologic procedures should be kept to a minimum consistent with adequate images. The present state of the art would indicate that the risk, if any, is minimal as contrasted with the natural incidence of breast cancer and the results of early diagnosis and treatment.

Adult↗
PubMed1977

Breast cancer mammography patterns.

Mammography studies, from 1963 through 1972, on 5,918 women over age 30 years with 327 breast cancer on initial studies, were prospectively categorized on a scale of 1 to 4 of increasing amounts of fibroglandular tissue. Approximately 60% of the cancers occurred in classes 1 and 2 breasts, about one-third of the patients, while 40% of the cancer were in the remaining two-thirds, comprising classes 3 and 4. There were 54 cancers that developed in breast that previously were free of symptoms, clinical signs, and x-ray abnormality. Up to 36 months one cancer was found in class 1, while 26 cancers were detected in class 4 breasts; two cancers developed in class 2 and seven in class 3. Cancers developing 38 to 88 months after normal examination had an incidence of 0.23% in combined classes 1 and 2 and an incidence of 0.21% in classes 3 and 4. Dense fibroglandular tissue delays detection of breast cancer by mammography. Apparent increase in cancer risk in such breasts is due to this delay. More than a 3-year follow-up is required to assess the life history of breast cancer by mammography.

Adult↗
PubMed1988

Mammography and palpable cancer of the breast.

The statistical analysis documented in this article was performed to determine the accuracy of mammography in diagnosing a palpable cancer of the breast. All of the women studied underwent mammography after the discovery of the cancer, which was proven by biopsy; the cancer did not involve the skin. All mammograms that demonstrated any abnormality in the area of the cancer were deemed to be positive. This study demonstrates that 22% of the women who have a palpable cancer of the breast will have a false-negative mammogram; 44% will be women of 50 and younger, and 13% will be women more than 50 years of age. Mammography is detrimental if used to avoid biopsy when there is a persistent mass, especially in younger women. It is concluded that biopsy should be performed on every undiagnosed, persistent, dominant mass without consideration of the mammogram.

Breast Neoplasms↗
PubMed1990

Issues in mammography.

The goals of screening mammography are reproducibly optimum images, accurately interpreted, at the lowest possible cost. This can reduce the mortality from breast cancer. Despite this, screening mammography has not been widely used because of the controversy over the age at onset and interval of screening, charge for the examination, misinformed primary care physicians, uninformed women, and other factors. The American College of Radiology's educational efforts and mammography accreditation program are overcoming some of these obstacles.

Adult↗
PubMed1991

Screening mammography.

Screening mammography can reduce mortality from breast cancer and is the only means of detecting nonpalpable cancers that are often more curable. Based on this, guidelines have evolved but compliance with them has been slow. Reservations are based on yield-cost-benefit-harm considerations, but uniformed and/or disadvantaged women and reluctance if not resistance to screening mammography by primary care physicians are major problems. The challenges are to overcome these obstacles and to obtain sufficient competent personnel and facilities to make reproducibly optimum screening mammography, which is accurately interpreted, widely available to all eligible women at the lowest possible cost.

Breast Neoplasms↗
PubMed1991

The contribution of routine follow-up mammography to an early detection of asynchronous contralateral breast cancer.

The role of routine mammography was assessed in the early detection of asynchronous contralateral breast cancer (ACBC). The breast cancer patient populations of two cities, Nijmegen and Eindhoven, The Netherlands, which were subjected to a well-defined follow-up program, were compared. The program consisted of regular physical examination and annual mammography in Nijmegen and physical examination only in Eindhoven. From 1975 until 1987, 24 ACBC patients were detected within a group of 880 breast cancer patients in Nijmegen (3%) and, from 1971 until 1984, 14 ACBC patients within a group of 411 patients in Eindhoven (3%). In Nijmegen, eight of the 23 evaluable patients (35%) had a contralateral tumor with a histologic size smaller than 10 mm or an in situ carcinoma, compared with one of the 14 of the Eindhoven patients (7%), whereas 18 of the 24 (75%) versus eight of the 14 patients (57%) were node-negative. Thus annual mammography is very likely a contribution in the early detection of contralateral breast cancer as compared with follow-up by regular physical examination only.

Breast Neoplasms↗
PubMed1991

Mammography and age: are we targeting the wrong women? A community survey of women and physicians.

To determine mammography use among women with a broad range of ages, the authors surveyed women aged 30 to 74 years and physicians practicing primary care in two eastern North Carolina counties. Twenty-five percent of women in their 30s had ever had a mammogram, and 34% intended to have one in the coming year. From 45% to 52% of women in their 40s, 50s, and 60s had ever had a mammogram, and 55% to 57% intended to have one in the next year. Thirty-seven percent of women aged 70 to 74 years had ever had a mammogram, and 40% intended to have one in the following year. Nineteen percent of physicians reported screening nearly all women aged 30 to 39 years, and 14% screened few women aged 50 to 74 years. Younger women were more worried about breast cancer than older women and assessed their risk as higher, attitudes that were generally associated with higher mammography utilization. These community surveys suggest that mammography use may be excessive among younger women; older women continue to be underscreened.

Adult↗
PubMed1993

Mammography utilization in the poor and medically underserved.

There is a significant difference in the utilization of mammography for screening and diagnosis between women of lower socioeconomic groups and the rest of the female population. Information obtained by the American Cancer Society through public hearings in 1989 revealed significant problems in how the poor deal with cancer. Barriers to methods of early detection seemed to revolve around access, education, and cost. A recent study of breast health performed by the Wirthlin Group for the American Cancer Society showed similar barriers. All women, regardless of income, expressed the fear of finding breast cancer as one of the major barriers to having mammography. Although the poor and medically underserved group of women showed similar barriers to mammography, certain barriers seemed specific to ethnic group, age, and place of residence. Evaluation of these barriers to breast health will allow the development of specific programs to meet the needs of this population.

Adolescent↗
PubMed1995

The excess of patients with advanced breast cancer in young women screened with mammography in the Canadian National Breast Screening Study.

BACKGROUND: An unexpected excess of patients with breast cancer with four or more positive lymph nodes was observed in mammographically screened women who were younger than the age of 50 years at enrollment into the Canadian National Breast Screening Study (NBSS). It has been suggested that this excess is consistent with prior screening trials evaluating mammography. METHODS: A quantitative evaluation of the distribution of patients with breast cancer with four or more positive lymph nodes in the NBSS was undertaken, and the percentages of patients with breast cancer who were at an advanced state at diagnosis in the NBSS and in previous randomized screening trials were compared. The validity of mortality analyses after eliminating advanced cases detected by physical examination at the initial screening visit is examined. RESULTS: The excess of patients with cancer with four or more positive lymph nodes in the 40-49-year mammography age group of the NBSS was statistically significant, even when expressed as a percentage of all invasive cancers diagnosed. Such an excess is inconsistent with published data on extent of disease at diagnosis from previous studies. Analysis of NBSS mortality data after eliminating advanced cases detected by physical examination at the initial visit should result in minimal, if any, bias. CONCLUSIONS: Mortality analyses eliminating advanced cases detected by physical examination at the initial screening visit may be less susceptible to bias caused by possible nonrandom allocation of study participants and should be considered in future evaluations of the NBSS cohort after longer follow-up periods and in meta-analyses that may include the NBSS in assessments of the efficacy of mammography.

Adult↗
PubMed2001

Yield of mammography in selected patients age < or = 30 years.

BACKGROUND: An outcomes analysis study was performed to quantify the benefit of directed diagnostic imaging of selected very young women (defined as < or = 30 years of age) in our population. Summary results are presented. PATIENTS AND METHODS: Women's Imaging Services were queried for studies performed between April 1, 1997 and December 31, 1998 on women < or = 30 years of age. The authors' referral pathway mandates breast examination by a general surgeon or by the head of Women's Imaging before mammography in all such patients. Studies were excluded if there were reviews of scans performed at other sites. The resulting 142 mammograms were evaluated. RESULTS: Ninety percent of the 142 studies were within normal limits. Only 11 mammograms indicated any required action (7.8%), and only 5 of these merited biopsy. All biopsies revealed benign disease. No carcinomas were detected by biopsy or on clinical follow-up in this cohort of women. These values are congruent with the scarce literature on mammography in this population. CONCLUSIONS: The yield of mammography in the age < or = 30 years population is low.

Adult↗
PubMed1984

Fine needle aspiration cytology, in relationships to clinical examination and mammography in the diagnosis of a solid breast mass.

The accuracy of clinical examination, mammography and fine needle aspiration cytology in identifying malignancy has been assessed in 1655 breast masses from two time periods. Clinical examination and mammography remained consistent at identifying malignancy but 9 per cent of all breast carcinomas were considered benign by both techniques (sensitivity 91 per cent). Fine needle aspiration cytology, when performed by multiple aspirators in the first study period, had a sensitivity of only 66 per cent for malignancy. During the second period of study, when all aspirates were performed by a single aspirator, sensitivity rose to 99 per cent. The two patients with false negative cytology in this latter period had both clinical and mammographic evidence of malignancy. No patient with malignant cytology was subsequently shown to have benign disease. It is concluded that a combination of clinical examination and mammography, with fine needle aspiration cytology performed by committed individuals with aptitude for the technique and interpreted by experienced pathologists, can identify all patients with breast cancer before surgery.

Adult↗
PubMed1991

Mammography in the management of patients with small breast cancers.

Findings on mammography resulted in a change of treatment policy in 17 of 200 patients with small breast cancers (T1/T2 less than 4 cm, N0/N1, M0). Twelve patients were considered unsuitable for conservation therapy because of mammographic evidence of either extensive in situ carcinoma or more than one focus of invasive carcinoma. These patients were treated by mastectomy and histology confirmed widespread in situ carcinoma or multifocal/multicentric invasive carcinoma. Seven patients were found to have unsuspected contralateral lesions on mammography, of which five were subsequently shown to be malignant. Routine preoperative mammography is essential in the management of patients with small breast cancers.

Adult↗