Original Research
3 September 2024

Association Between False-Positive Results and Return to Screening Mammography in the Breast Cancer Surveillance Consortium Cohort

Publication: Annals of Internal Medicine
Volume 177, Number 10
Visual Abstract. Association Between False-Positive Results and Return to Screening Mammography in the Breast Cancer Surveillance Consortium Cohort
Screening mammography is a part of routine well-woman care. It is important to understand how receipt of a false-positive mammography result may influence a woman's decision regarding whether and when to return for routine screening. This cohort study evaluates the association between screening mammography results and the probability of subsequent screening.

Abstract

Background:

False-positive results on screening mammography may affect women’s willingness to return for future screening.

Objective:

To evaluate the association between screening mammography results and the probability of subsequent screening.

Design:

Cohort study.

Setting:

177 facilities participating in the Breast Cancer Surveillance Consortium (BCSC).

Patients:

3 529 825 screening mammograms (3 184 482 true negatives and 345 343 false positives) performed from 2005 to 2017 among 1 053 672 women aged 40 to 73 years without a breast cancer diagnosis.

Measurements:

Mammography results (true-negative result or false-positive recall with a recommendation for immediate additional imaging only, short-interval follow-up, or biopsy) from 1 or 2 screening mammograms. Absolute differences in the probability of returning for screening within 9 to 30 months of false-positive versus true-negative screening results were estimated, adjusting for race, ethnicity, age, time since last mammogram, BCSC registry, and clustering within women and facilities.

Results:

Women were more likely to return after a true-negative result (76.9% [95% CI, 75.1% to 78.6%]) than after a false-positive recall for additional imaging only (adjusted absolute difference, −1.9 percentage points [CI, −3.1 to −0.7 percentage points]), short-interval follow-up (−15.9 percentage points [CI, −19.7 to −12.0 percentage points]), or biopsy (−10.0 percentage points [CI, −14.2 to −5.9 percentage points]). Asian and Hispanic/Latinx women had the largest decreases in the probability of returning after a false positive with a recommendation for short-interval follow-up (−20 to −25 percentage points) or biopsy (−13 to −14 percentage points) versus a true negative. Among women with 2 screening mammograms within 5 years, a false-positive result on the second was associated with a decreased probability of returning for a third regardless of the first screening result.

Limitation:

Women could receive care at non-BCSC facilities.

Conclusion:

Women were less likely to return to screening after false-positive mammography results, especially with recommendations for short-interval follow-up or biopsy, raising concerns about continued participation in routine screening among these women at increased breast cancer risk.

Primary Funding Source:

National Cancer Institute.

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Supplemental Material

Supplementary Material

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Katherine Hoekstra 9 September 2024
Payor mix

One possible factor the authors do not address is the possible copay for diagnostic imaging and procedures. ( e.g. most US health insurances do not entirely cover diagnostic mammograms) The Netherlands in general has a very low copay or none at all for diagnostic imaging and procedures, which would suggest that the reasons for lower rates of screening mammograms for women with false positive results, are not financially driven. For a lot of women the copays involved in the work up, especially after 2 false positive results after screening, start to add up in addition to time needed for scheduling, missed work and income.

Disclosures:

None

Diana Miglioretti, PhD 11 September 2024
Author Response to Hoekstra

We agree that out-of-pocket costs are a potential contributor to decreased probability of screening re-attendance following a false-positive result. We include the following in the discussion section: "Another potential contributor to discontinued screening may be financial concerns. Screening services are fully covered by most health plans under the Affordable Care Act;42 however, diagnostic imaging and biopsies typically incur out-pocket costs, which could dissuade future screening. (43-45) To address this issue, Washington State enacted legislation, effective January 1, 2024, mandating that health insurance plans cover diagnostic breast imaging examinations without any cost sharing by patients. (46)" We also mention financial and opportunity costs in the introduction: "However, screening mammography is also associated with potential harms including false-positive results that lead to additional imaging and biopsies, associated financial and opportunity costs, and patient anxiety.(1-6)"

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 177Number 10October 2024
Pages: 1297 - 1307

History

Published online: 3 September 2024
Published in issue: October 2024

Keywords

Authors

Affiliations

Diana L. Miglioretti, PhD https://orcid.org/0000-0002-5547-1833
Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, California, and Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington (D.L.M.)
Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington (L.A., E.J.A.B.)
Brian L. Sprague, PhD
Department of Surgery, Office of Health Promotion Research, Larner College of Medicine at the University of Vermont and University of Vermont Cancer Center, Burlington, Vermont (B.L.S.)
Christoph I. Lee, MD, MS https://orcid.org/0000-0002-8185-7721
Department of Radiology, University of Washington School of Medicine; Department of Health Systems and Population Health, University of Washington School of Public Health; and Hutchinson Institute for Cancer Outcomes Research, Seattle, Washington (C.I.L.)
Michael C.S. Bissell, PhD https://orcid.org/0000-0002-2414-4573
PicnicHealth, San Francisco, California (M.C.S.B.)
Thao-Quyen H. Ho, MD, PhD https://orcid.org/0000-0001-6314-937X
Department of Training and Scientific Research, University Medical Center, and Breast Imaging Unit, Diagnostic Imaging Center, Tam Anh General Hospital, Ho Chi Minh City, Vietnam (T.H.H.)
Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington (L.A., E.J.A.B.)
Louise M. Henderson, PhD https://orcid.org/0000-0001-8356-9267
Department of Radiology, University of North Carolina, Chapel Hill, North Carolina (L.M.H.)
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (R.A.H.)
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Dartmouth Cancer Center, Lebanon, New Hampshire (A.N.A.T.)
General Internal Medicine Section, Department of Veterans Affairs, and Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California (K.K.).
Acknowledgment: The authors thank the participating women, mammography facilities, and radiologists for the data they have provided for this study. Cancer and vital status data collection was supported by several state public health departments and cancer registries (www.bcsc-research.org/work/acknowledgement.html).
Grant Support: By grants P01CA154292, R01CA266377, and R50CA211115 from the National Cancer Institute. Additional support for data collection was provided by grant U54GM115516 from the National Institute of General Medical Sciences and by residual class settlement funds in the matter of Krueger v. Wyeth, Inc. (396 F.Supp.3d 931 [S.D. Cal. 2012]).
Reproducible Research Statement: Study protocol and statistical code: Available on reasonable request from the corresponding author. Data set: Available on reasonable request from the corresponding author with appropriate regulatory approvals.
Corresponding Author: Diana L. Miglioretti, PhD, University of California, Davis, Department of Public Health Sciences, Division of Biostatistics, One Shields Avenue, Med Sci 1C, Room 116, Davis, CA 95616; e-mail, [email protected].
Author Contributions: Conception and design: K. Kerlikowske, C.I. Lee, D.L. Miglioretti, B.L. Sprague, A.N.A. Tosteson.
Analysis and interpretation of the data: L. Abraham, M.C.S. Bissell, R.A. Hubbard, K. Kerlikowske, C.I. Lee, D.L. Miglioretti, B.L. Sprague, A.N.A. Tosteson.
Drafting of the article: L. Abraham, M.C.S. Bissell, T.H. Ho, C.I. Lee, D.L. Miglioretti.
Critical revision for important intellectual content: M.C.S. Bissell, E.J.A. Bowles, L.M. Henderson, R.A. Hubbard, K. Kerlikowske, C.I. Lee, D.L. Miglioretti, B.L. Sprague, A.N.A. Tosteson.
Final approval of the article: L. Abraham, M.C.S. Bissell, E.J.A. Bowles, L.M. Henderson, T.H. Ho, R.A. Hubbard, K. Kerlikowske, C.I. Lee, D.L. Miglioretti, B.L. Sprague, A.N.A. Tosteson.
Provision of study materials or patients: E.J.A. Bowles, L.M. Henderson, K. Kerlikowske, A.N.A. Tosteson.
Statistical expertise: L. Abraham, M.C.S. Bissell, R.A. Hubbard, D.L. Miglioretti.
Obtaining of funding: E.J.A. Bowles, L.M. Henderson, K. Kerlikowske, C.I. Lee, D.L. Miglioretti, B.L. Sprague, A.N.A. Tosteson.
Administrative, technical, or logistic support: K. Kerlikowske, D.L. Miglioretti.
Collection and assembly of data: L. Abraham, E.J.A. Bowles, L.M. Henderson, K. Kerlikowske, D.L. Miglioretti, B.L. Sprague, A.N.A. Tosteson.
This article was published at Annals.org on 3 September 2024.

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Diana L. Miglioretti, Linn Abraham, Brian L. Sprague, et al. Association Between False-Positive Results and Return to Screening Mammography in the Breast Cancer Surveillance Consortium Cohort. Ann Intern Med.2024;177:1297-1307. [Epub 3 September 2024]. doi:10.7326/M24-0123

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