Talya Salz

Systematic Review: The Long-Term Effects of False-Positive Mammograms

Context Do false-positive mammograms affect womens well-being and behavior? Contribution This systematic review summarizes data from 23 observational studies that compared outcomes after false-positive results or normal results on screening mammograms. Women who received false-positive results had slightly higher levels of distress and more thoughts about cancer several months after screening than women who received normal results. They also performed breast self-examinations more frequently and, in the United States, were slightly more likely to return for repeated routine screening examinations (risk ratio, 1.07 [95% CI, 1.02 to 1.12]). Implication False-positive mammograms may have persistent small effects on some womens psychological well-being and behavior. The Editors Regular mammography has become part of routine health care in the developed world for women 40 years of age or older. Routine mammography is important because it reduces death due to breast cancer by detecting tumors early (13). Unfortunately, many women receive false-positive results on screening tests. In the United States, approximately 11% of screening mammograms lead to false-positive results, which can cause women to incur substantial personal and financial costs related to follow-up testing (4, 5). One study (6) estimated that increased medical care use related to false-positive results on mammography costs

Meta‐analyses of the effect of false‐positive mammograms on generic and specific psychosocial outcomes

100 million per year in the United States. Researchers have shown that false-positive results negatively influence womens psychological well-being during the period immediately surrounding tests (7). Although researchers have performed several studies (79) on the effect of false-positive mammograms on women, the long-term effect is poorly understood. Women who receive false-positive mammograms may be discouraged from further routine screening mammographies (10). Testing errors could undermine womens confidence in the benefit of mammography and in the medical systems ability to provide adequate care, making them less likely to return for routine mammography. The costly and time-consuming follow-up procedures prompted by false-positive results may be an additional disincentive for return. Alternatively, false-positive mammograms may not have a negative effect on subsequent screening mammographies. Only one half of women with abnormal mammograms are aware of having received false-positive results (11). A recent survey in the United States found that of the adults who recall having received false-positive results on screenings for cancer (including mammographies), 98% were still glad that they had had the tests performed (12, 13). Women are concerned about receiving overdiagnosis and overtreatment but not about receiving false-positive results per se (14). A final and less commonly argued alternative is that false-positive results might actually increase routine screening because they increase anxiety, worry, and perceived risk (7, 1520). Anxiety, in turn, may cause women who receive false-positive results to be more vigilant about early detection than women who receive normal results. Although extreme anxiety caused by screening seems to be rare, abnormal mammograms apparently prompted 2 British women to commit suicide (21). Many studies have addressed the long-term consequences for women who receive false-positive mammograms, but these studies have yielded contradictory results, with different studies supporting each of the 3 possibilities described. Other reviews (7, 9, 18, 2225) emphasized short-term psychological consequences, largely ignored health behaviors, were typically not systematic reviews, and did not screen studies for minimum quality criteria. Because mixed findings among diverse outcomes have thwarted the understanding of the presence and extent of the long-term effects of false-positive screening mammograms, we conducted a systematic review of the relevant literature. We aimed to characterize the long-term effects of false-positive screening mammograms on the behavior and well-being of women 40 years of age or older. Methods Data Sources and Searches We conducted the review by using the following protocol. Two reviewers independently searched the MEDLINE, Web of Science, EMBASE, CINAHL, PsycINFO, and ERIC databases for studies published through September 2006 whose title, abstract, or keywords included reference to both false-positive results and screening mammography. The search terms were (false positive OR abnormal OR benign) AND (breast cancer OR mammog*). We also manually searched the reference sections of relevant papers and circulated requests for unpublished studies among colleagues and the authors of the articles we identified. We limited the searches to English-language studies. Study Selection Two reviewers independently screened the titles, then abstracts, and then text of articles that seemed pertinent. We identified studies that examined the effects of false-positive mammograms on the behavior, well-being, or beliefs of women 40 years of age or older by using selection criteria that we specified before the review began, except as noted. We excluded studies that did not meet the following quality criteria. We required that initial mammography screening results (abnormal or normal) be obtained from routine mammography because mammographies conducted for reasons other than screening take place in a very different context. We excluded studies of mammography prompted by symptoms or initial screening by clinical breast examination. We required that women receiving false-positive results be compared with women from the same sample who received normal results. Unacceptable comparison groups included unscreened women and women screened at other times or in different settings. We defined false-positive results on mammograms as abnormal results that did not lead to a cancer diagnosis after follow-up mammography, ultrasonography, magnetic resonance imaging, fine-needle aspiration, or biopsy. While reviewing the studies, we decided to include 2 studies (26, 27) that did not report the resolution of abnormal screening results because very few abnormal results indicate cancer (28). The inclusion of these studies did not change our findings. We required that initial screening be real (not imagined in a hypothetical vignette) and that results be assessed from medical records or by patient self-report. Studies had to include the outcome of return for routine screening within the interval recommended in the country or health system in which the study was conducted; we did not consider mammographies that were follow-ups of abnormal results or were part of a clinical trial as routine, initial mammographies. We required that women who returned for screening be assessed from medical or registry records or by patient self-report; however, we did not include intention to be screened as an acceptable measure. Additional outcomes included behavior, well-being, and beliefs, such as self-report of conducting breast self-examinations, anxiety, worry, perceived risk, and depression. We required that these outcome measures be assessed at least 1 month after cancer was ruled out so that the data reflected long-term consequences of false-positive screening results and not immediate distress in the period between receiving an abnormal test result and the subsequent negative result for cancer. Although breast self-examination has not been shown to reduce death due to breast cancer (29), we included it in our analysis as an additional demonstration of the effect of false-positive results on womens behavior. We required that studies reported bivariate statistical analyses of original, quantitative data or reported data that could be reanalyzed, although we accepted studies that reported null effects without indicating their size or direction. In practice, we did not exclude studies that reported results only after adjustment for covariates, although we excluded several studies that reported complex analyses that did not allow us to determine the relevant main effect. Data Extraction and Quality Assessment Two investigators independently used a standardized data extraction form to code the studies on characteristics that could alter the effect of receiving a false-positive result. In addition, we coded variables that reflect study quality, such as study design and use of self-report. During our review process, we refined our coding criteria to exclude study results for women whose follow-up for an abnormal mammogram was not further testing but was instead early recall for their next screening mammography. We could not exclude data for these women in 2 studies included in the review because data on women placed on early recall were combined with data on women receiving diagnostic follow-up in the study analyses (30, 31). Two investigators independently calculated a risk ratio for each study of return for the next routine mammogram. Data Synthesis and Analysis For studies assessing whether women returned for mammography, we pooled risk ratios (1 per study) by using a random-effects meta-analysis (32). For the 1 study (33) that reported data about reattendance at several time intervals after the initial mammogram, we chose data from month 18 of the study because that was the next period after the recommended screening interval of 12 months. Our analysis weighted risk ratios according to the sample size in each study while taking into account the variability among studies. We created a funnel plot to assess possible publication bias. We conducted the analyses by using the metan procedure in Stata (Stata Corp., College Station, Texas). We used 2-tailed statistical tests (critical = 0.05). Role of the Funding Sources The study was funded by grants from the University of North Carolina Lineberger Comprehensive Cancer Center and the American Cancer Society. The funding sources had no role in conducting the review or in preparing and submitti

The effect of hospital and surgeon volume on outcomes for rectal cancer surgery.

Objectives: While a previous meta‐analysis found that false‐positive mammography results affect womens likelihood of returning for screening, effects on well being have yet to be meta‐analyzed. We investigated whether the effects of false‐positive mammograms on womens well‐being are limited to outcomes specific to breast cancer.

Variation in use of surveillance colonoscopy among colorectal cancer survivors in the United States

Despite many studies of rectal cancer outcomes, no clear relationship between hospital or surgeon volume and patient outcomes has emerged for rectal cancer. We aimed to characterize the effect of hospital and surgical volume on surgery type and surgical outcomes in rectal cancer through a systematic review of the literature. We conducted a systematic review of studies evaluating the association between hospital or surgeon volume and rectal cancer outcomes. We searched PubMed for relevant articles and reviewed 23 articles. We describe each study and report outcomes in terms of the effect of hospital or surgeon volume on the type of surgery performed, surgical complications, postoperative mortality, survival, and recurrence. Hospitals and surgeons with higher caseloads appear to perform more sphincter-preserving surgeries and have lower postoperative mortality rates. Hospital and surgeon volume appear to have no effect or a small beneficial effect on the rate of leaks, complication rates, local recurrence, overall survival, and cancer-specific survival. For rectal cancer, the effects of hospital volume may be stronger for more short-term outcomes. Beyond the immediate recovery period, the effect of hospital and surgeon volume may be minimal. As more technically challenging surgeries, such as total mesorectal resection, become more widespread it will be important to evaluate the impact of hospital and surgeon volume on outcomes.

Survivorship care plans: Is there buy-in from community oncology providers?

BackgroundClinical practice guidelines recommend colonoscopies at regular intervals for colorectal cancer (CRC) survivors. Using data from a large, multi-regional, population-based cohort, we describe the rate of surveillance colonoscopy and its association with geographic, sociodemographic, clinical, and health services characteristics.MethodsWe studied CRC survivors enrolled in the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Eligible survivors were diagnosed between 2003 and 2005, had curative surgery for CRC, and were alive without recurrences 14 months after surgery with curative intent. Data came from patient interviews and medical record abstraction. We used a multivariate logit model to identify predictors of colonoscopy use.ResultsDespite guidelines recommending surveillance, only 49% of the 1423 eligible survivors received a colonoscopy within 14 months after surgery. We observed large regional differences (38% to 57%) across regions. Survivors who received screening colonoscopy were more likely to: have colon cancer than rectal cancer (OR = 1.41, 95% CI: 1.05-1.90); have visited a primary care physician (OR = 1.44, 95% CI: 1.14-1.82); and received adjuvant chemotherapy (OR = 1.75, 95% CI: 1.27-2.41). Compared to survivors with no comorbidities, survivors with moderate or severe comorbidities were less likely to receive surveillance colonoscopy (OR = 0.69, 95% CI: 0.49-0.98 and OR = 0.44, 95% CI: 0.29-0.66, respectively).ConclusionsDespite guidelines, more than half of CRC survivors did not receive surveillance colonoscopy within 14 months of surgery, with substantial variation by site of care. The association of primary care visits and adjuvant chemotherapy use suggests that access to care following surgery affects cancer surveillance.

Late Morbidity and Mortality in Patients With Hodgkin’s Lymphoma Treated During Adulthood

The Institute of Medicine recommended that survivors of cancer and their primary care providers receive survivorship care plans (SCPs) to summarize cancer treatment and plan ongoing care. However, the use of SCPs remains limited.

Electronic patient self-assessment and management (SAM): a novel framework for cancer survivorship

BACKGROUND Survivors of Hodgkins lymphoma (HL) treated as adults are at risk for late effects of therapy. However, the burden of late morbidity and mortality among adults treated for HL remains incompletely characterized. METHODS Vital status and, for deceased, cause of death were determined for 746 adults treated on a first-line trial at a single center from 1975 to 2000. Survivors completed a detailed survey describing their physical and mental health. A severity score (grades 1-4, ranging from mild to life-threatening or disabling) was assigned to self-reported conditions. RESULTS At a median follow-up of 22 years, 227 of patients (30.4%) had died, 107 (47.1%) from HL, 120 (52.9%) from other causes, including second primary malignancies (SPMs) (n = 52) and cardiovascular disease (n = 27). Across the duration of follow-up, all-cause and SPM-specific risk of death remained higher than predicted by normative data. Among survivors, late morbidity survey data are available for 238 patients (45.9%). Ninety-four-point-one percent of respondents reported at least one morbidity, and 47.5% reported at least one grade 3 or 4 morbidity; 20.2% reported two or more grade 3 morbidities. Commonly reported morbidities included cardiovascular (54.6%), endocrine (68.5%), pulmonary disease (21.4%), and nonfatal second malignancy (23.1%). Anxiety, depression, and fear of recurrence were frequently reported. CONCLUSIONS Among a large cohort of patients treated for HL with extensive follow-up, risk of late mortality from causes other than HL and prevalence of late medical morbidity are high. Guidelines for prevention, screening, and management of late effects in adult survivors of HL are needed.

False positive mammograms in Europe: do they affect reattendance?

BackgroundWe propose a novel framework for management of cancer survivorship: electronic patient Self-Assessment and Management (SAM). SAM is a framework for transfer of information to and from patients in such a way as to increase both the patients and the health care providers understanding of the patients progress, and to help ensure that patient care follows best practice.MethodsPatients who participate in the SAM system are contacted by email at regular intervals and asked to complete validated questionnaires online. Patient responses on these questionnaires are then analyzed in order to provide patients with real-time, online information about their progress and to provide them with tailored and standardized medical advice. Patient-level data from the questionnaires are ported in real time to the patients health care provider to be uploaded to clinic notes. An initial version of SAM has been developed at Memorial Sloan-Kettering Cancer Center (MSKCC) and the University of California, San Francisco (UCSF) for aiding the clinical management of patients after surgery for prostate cancer.ResultsPilot testing at MSKCC and UCSF suggests that implementation of SAM systems are feasible, with no major problems with compliance (> 70% response rate) or security.ConclusionSAM is a conceptually simple framework for passing information to and from patients in such a way as to increase both the patients and the health care providers understanding of the patients progress, and to help ensure that patient care follows best practice.

Colorectal Cancer Survivors' Needs and Preferences for Survivorship Information

False positive results from screening mammography are quite common in the United States, with almost half of women receiving at least one false positive result over 10 years of annual screening [1]. In Europe, false positive mammography results are likely less common, as European countries report many fewer abnormal mammogram results and, on the whole, have similar breast cancer detection rates [2–5]. Reasons for lower false positive rates in Europe may include a less litigious environment, having higher quality standards, having the double-viewing of film be more common practice, having higher tolerance for missing breast cancer (false negatives), requiring higher volume for radiologists interpreting mammograms, and radiologists having access to patients’ previous screening records [6, 7]. Even with these safeguards, many European women experience false positive mammograms.

Who gets genomic testing for breast cancer recurrence risk

PURPOSE Before developing a survivorship care plan (SCP) that colorectal cancer (CRC) survivors will value, understanding the informational needs of CRC survivors is critical. METHODS We surveyed survivors treated for nonmetastatic CRC at two hospitals in New York about their needs and preferences for survivorship information. Participants completed treatment 6 to 24 months before the interview and had not received an SCP. We evaluated whether survivors knew their treatment history (10 topics), whether they understood ongoing risks (four topics), and their preferences for receiving 16 topics of survivorship information. RESULTS One hundred seventy-five survivors completed the survey. Most survivors remembered information about past treatment (98% to 99% for each treatment). Fewer survivors knew their risks of local recurrence, distant recurrence, or developing a new CRC (69%, 77%, and 40%, respectively). Most participants reported receiving information about their cancer history and ongoing oncology visits (77% to 86% across topics). Across all topics, 93% to 99% of those who reported receiving information found the information useful. A minority of survivors reported they received information about symptoms to report to doctors, returning to work, or financial or legal issues (5% to 48% across topics), but those who did found the information useful (89% to 100% across topics). CONCLUSIONS In the absence of an SCP, CRC survivors still generally understood their cancer history. However, many lacked knowledge of ongoing risks and prevention. Most survivors stated that they found the survivorship information they received useful. SCPs for CRC survivors should focus less on past care and more on helping survivors understand their risks and plan for the future.