Suzanne W. Fletcher

TEN-YEAR RISK OF FALSE POSITIVE SCREENING MAMMOGRAMS AND CLINICAL BREAST EXAMINATIONS

BACKGROUND The cumulative risk of a false positive result from a breast-cancer screening test is unknown. METHODS We performed a 10-year retrospective cohort study of breast-cancer screening and diagnostic evaluations among 2400 women who were 40 to 69 years old at study entry. Mammograms or clinical breast examinations that were interpreted as indeterminate, aroused a suspicion of cancer, or prompted recommendations for additional workup in women in whom breast cancer was not diagnosed within the next year were considered to be false positive tests. RESULTS A total of 9762 screening mammograms and 10,905 screening clinical breast examinations were performed, for a median of 4 mammograms and 5 clinical breast examinations per woman over the 10-year period. Of the women who were screened, 23.8 percent had at least one false positive mammogram, 13.4 percent had at least one false positive breast examination, and 31.7 percent had at least one false positive result for either test. The estimated cumulative risk of a false positive result was 49.1 percent (95 percent confidence interval, 40.3 to 64.1 percent) after 10 mammograms and 22.3 percent (95 percent confidence interval, 19.2 to 27.5 percent) after 10 clinical breast examinations. The false positive tests led to 870 outpatient appointments, 539 diagnostic mammograms, 186 ultrasound examinations, 188 biopsies, and 1 hospitalization. We estimate that among women who do not have breast cancer, 18.6 percent (95 percent confidence interval, 9.8 to 41.2 percent) will undergo a biopsy after 10 mammograms, and 6.2 percent (95 percent confidence interval, 3.7 to 11.2 percent) after 10 clinical breast examinations. For every 100 dollars spent for screening, an additional 33 dollars was spent to evaluate the false positive results. CONCLUSIONS Over 10 years, one third of women screened had an abnormal test result that required additional evaluation, even though no breast cancer was present. Techniques are needed to decrease false positive results while maintaining high sensitivity. Physicians should educate women about the risk of a false positive result from a screening test for breast cancer.

Efficacy of Prophylactic Mastectomy in Women With Unilateral Breast Cancer: A Cancer Research Network Project

PURPOSE We investigated the efficacy of contralateral prophylactic mastectomy (CPM) in reducing contralateral breast cancer incidence and breast cancer mortality among women who have already been diagnosed with breast cancer. METHODS This retrospective cohort study comprised approximately 50,000 women who were diagnosed with unilateral breast cancer during 1979 to 1999. Using computerized data confirmed by chart review, we identified 1,072 women (1.9%) who had CPM. We obtained covariate information for these women and for a sample of 317 women who did not undergo CPM. RESULTS The median time from initial breast cancer diagnosis to the end of follow-up was 5.7 years. Contralateral breast cancer developed in 0.5% of women with CPM, metastatic disease developed in 10.5%, and subsequent breast cancer developed in 12.4%; 8.1% died from breast cancer. Contralateral breast cancer developed in 2.7% of women without CPM, and 11.7% died of breast cancer. After adjustment for initial breast cancer characteristics, treatment, and breast cancer risk factors, the hazard ratio (HR) for the occurrence of contralateral breast cancer after CPM was 0.03 (95% CI, 0.006 to 0.13). After adjustment for breast cancer characteristics and treatment, the HRs for the relationship of CPM with death from breast cancer, with death from other causes, and with all-cause mortality were 0.57 (95% CI, 0.45 to 0.72), 0.78 (95% CI, 0.57 to 1.06), and 0.60 (95% CI, 0.50 to 0.72), respectively. CONCLUSION CPM seems to protect against the development of contralateral breast cancer, and although women who underwent CPM had relatively low all-cause mortality, CPM also was associated with decreased breast cancer mortality.

Clinical research in general medical journals: a 30-year perspective.

Little is known about the frequency with which various research designs appear in the clinical literature and how this frequency has changed in recent years. This study describes the research designs used in 612 articles randomly selected from original research published in three general medical journals from 1946 to 1976. Cross-sectional studies increased from 25 to 44 per cent, cohort studies declined from 59 to 34 per cent, and clinical trials increased from 13 to 21 per cent of articles (P less than 0.001). Randomized controlled trials comprised 5 per cent of articles published in 1976 and were not represented 30 years before. In 1976, 37 per cent of articles reported on 10 subjects or less, and this number has not changed substantially since 1946. The frequency of studies with weak research designs has increased in these general medical journals over the past 30 years. The trend deserves critical attention.

The characteristics of peer reviewers who produce good-quality reviews

Objective: To determine the characteristics of good peer reviewers.Design: Cross-sectional analysis of data gathered during a randomized controlled trial.Setting: The Journal of General Internal Medicine.Participants: 226 reviewers of 131 consecutively submitted manuscripts of original research. 201 (91%) completed the review and submitted a curriculum vitae.Measurements and main results: The quality of each review was judged on a scale from 1 to 5 by an editor who was blinded to the identity of the reviewer. Reviewer characteristics were taken from the curricula vitae. 86 of the 201 reviewers (43%) produced good reviews (a grade of 4 or 5). Using logistic regression, the authors found that when a reviewer was less than 40 years old, from a top academic institution, well known to the editor choosing the reviewer, and blinded to the identity of the manuscript’s authors, the probability that he or she would produce a good review was 87%, whereas a reviewer without any of these characteristics had a 7% probability of producing a good review. Other characteristics that were significant only on bivariate analysis included previous clinical research training, additional postgraduate degrees, and more time spent on the review. There was a negative but statistically nonsignificant association between academic rank and review quality: 37% of full professors, 39% of associate professors, and 51% of assistant professors or fellows produced good reviews (p=0.11).Conclusions: Good peer reviewers for this journal tended to be young, from strong academic institutions, well known to the editors, and blinded to the identity of the manuscript’s authors.

Can Residents Be Trained to Counsel Patients about Quitting Smoking? Results from a Randomized Trial

Study objective:To evaluate the effectiveness of two teaching interventions to increase residents’ performance of smoking cessation counseling.Design:Randomized controlled factorial trial.Setting:Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals.Participants:261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months.Interventions:Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention.Measurement and results:Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5–1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76–79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3–8.2%; biochemically verified: 3.4–5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant.Conclusion:A simple and feasible educational intervention can increase residents’ smoking cessation counseling.

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.

Contentment With Quality of Life Among Breast Cancer Survivors With and Without Contralateral Prophylactic Mastectomy

PURPOSE To understand psychosocial outcomes after prophylactic removal of the contralateral breast in women with unilateral breast cancer. METHODS We mailed surveys to women with contralateral prophylactic mastectomy after breast cancer diagnosis between 1979 and 1999 at six health care delivery systems, and to a smaller random sample of women with breast cancer without the procedure. Measures were modeled on instruments developed to assess contentment with quality of life, body image, sexual satisfaction, breast cancer concern, depression, and health perception. We examined associations between quality of life and the other domains using logistic regression. RESULTS The response rate was 72.6%. Among 519 women who underwent contralateral prophylactic mastectomy, 86.5% were satisfied with their decision; 76.3% reported high contentment with quality of life compared with 75.4% of 61 women who did not undergo the procedure (P = .88). Among all case subjects, less contentment with quality of life was not associated with contralateral prophylactic mastectomy or demographic characteristics, but was associated with poor or fair general health perception (odds ratio [OR], 7.0; 95% CI, 3.4 to 14.1); possible depression (OR, 5.4; 95% CI, 3.1 to 9.2); dissatisfaction with appearance when dressed (OR, 3.5; 95% CI, 2.0 to 6.0); self-consciousness about appearance (OR, 2.0; 95% CI, 1.1 to 3.7); and avoiding thoughts about breast cancer (modest: OR, 2.2; 95% CI, 1.1 to 4.5; highest: OR, 1.7; 95% CI, 0.9 to 3.2). CONCLUSION Most women undergoing contralateral prophylactic mastectomy report satisfaction with their decision and experience psychosocial outcomes similar to breast cancer survivors without the procedure.

Increased patient concern after false-positive mammograms: clinician documentation and subsequent ambulatory visits.

OBJECTIVE: To measure how often a breast-related concern was documented in medical records after screening mammography according to the mammogram result (normal, or truenegative vs false-positive) and to measure changes in health care utilization in the year after the mammogram.DESIGN: Cohort study.SETTING: Large health maintenance organization in New England.PATIENTS: Group of 496 women with false-positive screening mammograms and a comparison group of 496 women with normal screening mammograms, matched for location and year of mammogram.MEASUREMENTS AND MAIN RESULTS: 1) Documentation in clinicians’ notes of patient concern about the breast and 2) ambulatory health care utilization, both breast-related and non-breast-related, in the year after the mammogram. Fifty (10%) of 496 women with false-positive mammograms had documentation of breast-related concern during the 12 months after the mammogram, compared to 1 (0.2%) woman with a normal mammogram (P=.001). Documented concern increased with the intensity of recommended follow-up (P=.009). Subsequent ambulatory visits, not related to the screening mammogram, increased in the year after the mammogram among women with false-positive mammograms, both in terms of breast-related visits (incidence ratio, 3.07; 95% confidence interval [CI], 1.69 to 5.93) and non-breast-related visits (incidence ratio, 1.14; 95% CI, 1.03 to 1.25).CONCLUSIONS: Clinicians document concern about breast cancer in 10% of women who have false-positive mammograms, and subsequent use of health care services are increased among women with false-positive mammogram results.

Improving emergency-room patient follow-up in a metropolitan teaching hospital. Effect of a follow-up check.

Abstract A randomized controlled study was conducted to determine whether addition of a Follow-up Clerk to the emergency-room staff would improve compliance among emergency-room patients requiring ...

Positive, Negative, and Disparate—Women’s Differing Long‐Term Psychosocial Experiences of Bilateral or Contralateral Prophylactic Mastectomy

Abstract:  Because of recent studies showing strong prevention benefit and acceptable psychosocial outcomes, more women may be considering prophylactic mastectomy. A growing literature shows some positive psychosocial outcomes for women with bilateral prophylactic mastectomy, but less is known about women with contralateral prophylactic mastectomy. Several surveys have shown that a large majority of women with prophylactic mastectomy report satisfaction with their decisions to have the procedure when asked in a quantitative, closed‐ended format. We sought to explore the nuances of women’s satisfaction with the procedure using a qualitative, open‐ended format. We included open‐ended questions as part of a mailed survey on psychosocial outcomes of prophylactic mastectomy. The research team coded and analyzed these responses using qualitative methods. We used simple descriptive statistics to compare the demographics of the entire survey sample to those women who answered the open‐ended questions; the responses to the open‐ and closed‐ended satisfaction questions, and the responses of women with bilateral and contralateral prophylactic mastectomy. Seventy‐one percent of women with prophylactic mastectomy responded to the survey and 48% provided open‐ended responses about psychosocial outcomes. Women’s open‐ended responses regarding psychosocial outcomes could be coded into one of three general categories—positive, negative, and disparate. In the subgroup of women with both open‐and closed‐ended responses, over 70% of women providing negative and disparate comments to the open‐ended question simultaneously indicated satisfaction on a closed‐ended question. Negative and disparate open‐ended responses were twice as common among women with bilateral prophylactic mastectomy (52%) than women with contralateral prophylactic mastectomy (26%). These findings suggest that even among women who report general satisfaction with their decision to have prophylactic mastectomy via closed‐ended survey questions, lingering negative psychosocial outcomes can remain, particularly among women with bilateral prophylactic mastectomy. This dichotomy could be an important factor to discuss in counseling women considering the procedure.