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Mammography reduces mortality from breast cancer, but it still is underused. This article provides an overview of barriers and facilitators to mammography. Additionally, clinical strategies for increasing mammography use are presented.
The purpose of this study was to examine the relationship between theoretically identified variables and participation in mammography screening in a university workplace. A sample of 1093 women 50 and over returned a questionnaire following the offer of a free workplace breast cancer screening. Anderson's Behavioral Model of Health Services Use identified factors predisposing and enabling women to have mammograms. Predisposing variables included attitudes and experience related to mammography. Enabling variables included income, willingness to pay for mammography, health insurance coverage, and regular source of health care. Comparisons were made among: (i) those who were screened in the workplace, (ii) those who were screened elsewhere, and (iii) those who were not screened. Differences in perceived barriers, perceived benefits, practice of breast self-examination (BSE), and education surfaced. Results indicated, among other things, that women who were older, had no more than 12 years of education, had a family member with breast cancer, and were proficient with breast self-examination were more likely to have participated in the university work-site screening.
Hormone replacement therapy (HRT) in post-menopausal or ovariectomized women reduces mortality due to cardiovascular diseases, lowers morbidity due to osteoporosis and improves vasovagal symptoms. Long-term therapy, however, increase the risk of side-effects. HRT may decrease mammographic sensitivity, markedly increasing glandular density. Enlargement of pre-existing cysts and fibroadenomas has also been reported after HRT. The correlation between HRT and breast cancer is highly controversial. We examined 650 women: 550 of them (84.6%) received HRT (157 estrogens and 393 estrogens-progestins) and 100 (15.4%) refused treatment and were thus considered as a control group. All patients underwent mammography and DEXA before HRT and, during treatment, were followed-up yearly with mammography, often combined with US, and DEXA. Fisher's test was used for data analysis (confidence interval: 95%). The statistical analysis showed a significant difference between the HRT group and the control group only for the lumbar spine. Mammographic changes (Tab. II) were shown in 150 of 550 HRT patients. Increased breast density was the most frequent finding. Benign lesions arising de novo or increasing in size and/or number were observed in 41 of 150 patients (27.3%) in the HRT group, where 3 breast carcinomas were detected, versus 1 breast cancer only in the control group. HRT had a marked positive effect on bone mineral content (BMC) at 2 years' follow-up, but it remains debated if it reduces breast cancer risk. In conclusion, our results indicate that a yearly mammography is mandatory in long-term HRT subjects and US may be also needed in particularly dense breasts.
Present day mammography has not been able to make use of the advantages of digital luminescence radiography because of the limited spatial resolution. The recent development of electromagnetic focusing x-ray tube with effective focal spot sizes from 0.04 to 0.12 mm allows radiographic direct magnification with less geometric blur. It is now possible to combine direct magnification mammography with digital luminescence radiography. By combining high quality storage phosphor screens with an HQ-workstation a spatial resolution of 8 lp/mm is possible for 1.7-fold magnification. For 4-fold spot magnification views spatial resolution can be theoretically increased to approx. 20 lp/mm. One important advantage of digital radiography is the possibility of image-post-processing. This article presents two sets of standard parameters and three sets of image dependent parameters for better imaging of specific lesions, such as microcalcifications. The introduction of the the storage phosphor screen technique in mammography is one step in the development of direct digital radiography. Further interesting perspectives for the future include post-processing programs for detecting suspicious lesions which are already being clinical tested.
Mass screening programs to detect breast cancer are currently under way in many countries. In France, several districts have been running mammographic screening programs since 1989. A survey was conducted in five of these districts and in a sixth district where no screening program was implemented. Using a self-addressed questionnaire mailed to a sample of 1500 women aged over 20 years, the survey was aimed at assessing women's use of mammography as well as their knowledge and perception of mammographic breast cancer screening. According to district, the compliance of the women replying to the questionnaire ranged from 72 to 82%. The proportion of women who had at least one mammography during their life ranged from 41 to 54%, according to district. The percentage of women aged 50 to 69 who had one mammography within 3 years before the survey ranged from 57 to 78% in the experimental districts and was only 48% in the control district. In all districts, women did not know exactly at what age it is recommended to start screening and with what periodicity, but, when invited to do so, they were satisfied with the program and intended to participate again.
Mammography has been performed routinely preoperatively over the last 5 years on 278 patients with breast tumors. In 85 per cent the radiographic findings showed an exact correlation to histologic results. In 12 per cent there was only a partial correlation, in only 3 per cent the mammograpic findings could not be verified by the pathologist. The purpose of this paper is to emphasize that mammography should be considered as the prime diagnostic procedure in the diagnosis of breast disease. The examination of the breast should therefore always be followed by mammography, especially in women at risk and elderly patients. In this connection we would also like to stress the vital cooperation between the radiologist and surgeon both pre- and intraoperatively. and intraoperatively. In summary we would like to emphasize the importance of possibility to achieve a better survial rate in these patients.
Among women aged 50 to 69 years, regular screening by mammography in combination with clinical examination, can substantially decrease the morbidity and mortality associated with breast cancer by facilitating early detection. Unfortunately, many Canadian women are not screened in accordance with current guidelines. Research to date is based primarily on large surveys conducted in the United States and less is known about the relevance of specific barriers to mammography screening among Canadian women. Multivariate results from the 1994-95 National Population Health Survey (NPHS) indicate that younger (40-49) and older (70+) women, those who are socioeconomically disadvantaged, and minority women are least likely to report having had a mammogram. Conversely, women with positive health behaviours, high social support, and positive mental health attributes are more likely to participate in mammography screening. These findings are discussed in terms of the implications for developing successful intervention programs for Canadian women and for setting priorities for further research.
On the basis of a series of 60 cases, the authors report their experience of excision of grouped microcalcifications detected at mammography in the absence of any clinical sign. The breast zone in which the microcalcifications were located by the radiologist was removed surgically. Per-operatoire X-ray of the excised specimens using a mammography apparatus confirmed that the microcalcifications had been totally removed. In addition it was useful to locate aceuretaly the calcifications in view of a careful histological examination of the area. The technique led to the discovery of 27 carcinomas at a sub-clinical stage. A classification of the various types of microcalcification was established in relation to histology. It will be of assistance in suspecting malignancy on the basis of mammography findings in the majority of cases. Excision can then be reserved for cases of presumed malignancy or where a doubt exists. By detecting breast carcinomas at a sub-clinical stage, the method makes possible early and minimally mutilating treatment with the best chances of cure.
The Mammography Quality Assurance Programme, recently established by the Royal Australasian College of Radiologists, has processed the first 50 applications. This programme, which closely follows the programme of the American College of Radiology (ACR), utilizes phantom film images, thermoluminescent dosimetry measurement of mean glandular dose, processor control charts, clinical images, equipment reports and required survey information to establish that a centre conforms to a minimum standard in mammography. The present paper describes the initial results of the first phantom images, dose measurements, processor control and survey information. A film review panel of six members has been trained in phantom film reading. Their evaluation of phantom films was compared with film readings by members of the ACR and was found to be in close agreement. Fifty films have been evaluated up to the present time with a failure rate of 26%. The major causes of failure were unacceptable film artefacts and poor contrast (as indicated by reduced fibre and mass visibility). A surprising result was the high failure in processing, where 23% of units reviewed had significant problems, including failure to keep the processor within required control limits. Only one centre recorded a mean glandular dose above 2 mGy with no centre over the 3 mGy limit. A review of the frequency of the quality control testing shows that the acceptance of quality assurance in mammography, while greater than in the initial stages of the ACR programme, is less than current US practice. These initial results for the accreditation process probably reflect an initial period of adjustment, as seen by the high pass rate achieved by centres that have resubmitted material to gain accreditation.
Especially in breast reconstruction after mastectomy, subcutaneous mastectomy, or extensive lumpectomy, the radiological properties of breast implants play an important role. Mammography is still the gold standard for follow-up diagnostics as well as for preventive diagnostics, and the interpretation of these films is greatly influenced by the type of the implant filler material. In this study, in vivo conditions are simulated, and standard mammography techniques applied to examine the effects of various types of implants on the readability of mammography films using semiquantitative measurements as well as subjective judgement by independent radiologists.
Xeroradiography is a valuable supplement to conventional mammography, especially in cases with dense glandular structure. In our patient material this new procedure was necessary for clarification of findings on conventional mammography in 16% of cases and improved diagnostic yield. Indirect and direct signs of carcinoma were more easely recognized with xeroradiography, since more detail is visualized because of greater latitude and edge contrast enhancement. Moreover the area visualized is considerably greater. The soft tissue structures can be seen to the level of the thoracic wall. Viewing the films is less tiring than reviewing conventional mammography films. A relatively greater exposure latitude and short exposure times are further advantages of this method.
There is little information regarding flow cytometric DNA analyses of benign breast lesions. This prospective study consists of mammographic and pathological correlation of DNA flow cytometric analyses of specimen mammography-guided fine-needle aspirates (FNAs) of 189 consecutive benign breast lesions and 114 FNAs of adjacent normal tissue as a control. Clinical follow-up was also performed. Aneuploidy was detected in 14 of 189 (7%) benign lesion specimen mammography-guided FNAs and in only 1 of 114 (0.9%) FNAs of adjacent normal tissue (P = 0.01). Aneuploidy was detected in two (33%) benign intramammary lymph nodes compared with four (12%) benign lesions with atypia, one benign lesion (3%) with hyperplasia, four benign lesions (10%) with adenosis, and three (4%) other benign lesions (P = 0.01). There were no significant associations between DNA content and S-phase percentage and patient age, mammographic appearance, or extent. During a median follow-up of 40 months (range, 6-84 months), 2 of 13 (15%) patients with aneuploid benign lesions developed ipsilateral breast carcinoma compared with 5 of 175 (3%) patients with diploid benign lesions (odds ratio, 6.18; 95% confidence interval, 1.08-35.56). Our data suggest that aneuploidy, which is detected in a variety of benign breast lesions, may be associated with a higher risk of development of breast carcinoma. The combined techniques of specimen mammography-guided fine-needle aspiration and flow cytometry provide a practical translational research method for the study of benign breast disease.
Data from a telephone survey of women participating in a federally funded screening program were used to demonstrate the sensitivity of mammography compliance estimates to varying definitions of the time interval within which women are considered compliant with screening guidelines and what constitutes a true screening (as opposed to diagnostic) mammogram. The survival analysis approach used reveals patterns concealed by other approaches to measuring mammography behavior and provides a means for quantifying the impact of various definitional choices on compliance estimates. The results suggest that, although variations in defining and excluding potential diagnostic mammograms lead to differences in compliance measures no greater than 6%, differences as small as 1 month in the screening interval definition used can produce differences in compliance estimates as large as 27%. These results call into question the comparability of estimates across studies and suggest that standard measures would greatly facilitate future efforts in understanding how to promote compliance with mammography screening guidelines.
We undertook this study to test whether progressive intervention would increase the use of mammography. In 1995, we randomly assigned into 2 groups 717 underserved women veterans in the Veterans Affairs Palo Alto (California) Health Care System (VAPAHCS) who earned less than $22,000 a year. The women were sent an informational letter and brochure explaining why mammography is needed and how often. The letter further requested that if the woman was due for a screening mammogram or if a lump or other recent change in her breast had occurred, that she call for scheduling of a free mammogram and a visit to the breast clinic. Women in group I (n = 351) received no further intervention. Women in group II (n = 366) received a follow-up phone call by a breast care nurse if they had not responded within 45 days of the informational mailing. The nurse talked to each woman about her particular needs, explained to her that the screening mammogram would be provided free of charge, and discussed transportation arrangements to the mammography facility. A total of 17 women in group I had mammograms versus 100 in group II during the same time period. We conclude that the additional intervention of a phone call by a breast care nurse increased use by more than 5-fold, which reached significance (P < .01).
In the United States, breast cancer is the most commonly diagnosed malignancy among women and the second leading cause of cancer death. Lack of health insurance coverage often is an important financial barrier to seeking preventive health care such as mammography screenings. To assess mammography use and the impact of insurance status on mammography use, state-specific proportions of women aged > or =40 years who reported receiving a mammogram during the preceding 2 years by insurance status were derived using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1991-1992 and 1996-1997. This report describes the results of this analysis, which indicate that the percentage of women reporting having had a screening mammogram during the previous 2 years increased, but women with insurance were substantially more likely than women without insurance to have had a mammogram.
PURPOSE: The objective of our study was to test the reliability of dynamic, contrast-enhanced MR-mammography (MR-M) in the detection of invasive lobular carcinoma (ILC) and to test if additional examination with MR-M increases the sensitivity of conventional mammography (Mx) in the detection of ILC. MATERIAL AND METHODS: We carried out 1,505 MR-Mammographies in 1,357 patients. Biopsy was indicated in 413 cases. Among the malignancies, 23/214 (10.7%) were ILC. MR-M was performed with a 1.0 T whole body MRI system with a dynamic FLASH-3D sequence. Relative signal enhancement within lesions detected and morphologic pattern of contrast enhancement (mep) were determined. Three types of mep were distinguished: type 1 without contrast enhancement, type 2 with focal contrast enhancement and type 3 with diffuse contrast enhancement of the glandular body. RESULTS: Within MR-M alone, 19/23 (82.6%) of ILC were detected due to a mep type 2. Four ILC were false negative on MR-M (2 cases show mep type 1 or mep type 3). The sensitivity of Mx alone was 86.9% (20/23). When both Mx and MR-M were combined, all 23 ILC were detected. The addition of MR-M to Mx may increase sensitivity to about 100% in the detection of ILC. CONCLUSION: Unsuspicuous MR-M (mep type 1) or diffuse uptake of contrast media (mep type 3) does not rule out malignancy in the presence of suspicious findings at Mx.
The purpose of this study was to correlate physical examination and sonographic and mammographic measurements of breast tumors and regional lymph nodes with pathological findings and to evaluate the effect of neoadjuvant chemotherapy on clinical Tumor-Node-Metastasis stage by noninvasive methods. This was a retrospective analysis of 100 patients with locally advanced breast cancer registered and treated in prospective trials of neoadjuvant chemotherapy. All patients received four cycles of a doxorubicin-containing regimen and had noninvasive evaluation of the primary tumor and regional lymph nodes before and after neoadjuvant chemotherapy by physical examination, sonography, and mammography and underwent breast surgery and axillary dissection within 5 weeks after completion of neoadjuvant chemotherapy. The correlations between clinical and pathological measurements were determined by Spearman rank correlation analysis. A proportional odds model was used to examine predictive values. Eighty-three patients had both a clinically detectable primary tumor and lymph node metastases. Sixty-four patients had a decrease in Tumor-Node-Metastasis stage after chemotherapy. For 54% of patients, there was concordance in clinical response between the primary tumor and lymph node compartment; for the rest, results were discordant. Physical examination correlated best with pathological findings in the measurement of the primary tumor (P = 0.0003), whereas sonography was the most accurate predictor of size for axillary lymph nodes (P = 0.0005). The combination of physical examination and mammography worked best for assessment of the primary tumor (P = 0.003), whereas combining physical examination with sonography gave optimal evaluation of regional lymph nodes (P = 0.0001). In conclusion, physical examination is the best noninvasive predictor of the real size of locally advanced primary breast cancer, whereas sonography correlates better with the real dimensions of axillary lymph nodes. The combination of physical examination with either mammography or sonography significantly improves the accuracy of noninvasive assessment of tumor dimensions.
Regular screening mammography is recommended to reduce breast cancer mortality. Although predictors of mammography have been studied, factors that influence adherence to guidelines are less understood. We examined the relationship between an index mammogram and subsequent mammograms among California Medicare beneficiaries. Medicare billing data for 1992, 1993, and 1994 were used to estimate the association between screening mammography in 1992 and subsequent screening in 1993 or 1994. We found that women with a 1992 mammogram were more than twice as likely to have a mammogram in 1993 or 1994 than women without a 1992 mammogram (relative risk = 2.58; 95% confidence interval, 2.57-2.59). This relationship was somewhat stronger for black women compared with white women and increased with age. Although further study of regular screening patterns is needed, these findings provide some evidence that encouraging a single mammogram may lead to continued adherence.