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BREAST CANCER SCREENING AND COMPLIANCE AND EVALUATION OF LESIONS
CANCER SCREENING AND DIAGNOSIS
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BREAST CANCER SCREENING AND COMPLIANCE AND EVALUATION OF LESIONS David V. Schapira, MBChB, FRCP(C), and Richard B. Levine, MD
BREAST CANCER SCREENING AND COMPLIANCE Breast Cancer Screening Studies and Guidelines
Screening mammography is the term used to define an attempt to detect unsuspected breast cancer in asymptomatic women.28This screening mammogram may be referred from another physician or can be selfreferred by the patient herself. Screening mammography programs are designed to reach large numbers of women so that examinations may be done quickly, usually without physician supervision on site, processed either on site or in a central location, and then batch read by the radiologist at one location to separate the normal from the abnormal mammogram. This process also keeps the costs reasonable to the patient and encourages increased use. Screening mammography is incomplete without a physical examination, which may be done by the referring physician or the radiologist depending on the physical setup at the mammography facility. The woman who is self-referred must be willing to be referred to another physician for follow-up care in the case of an abnormal mammogram. The selection of this physician may be guided by the radiologist depending on the problem to be dealt with. Historically, breast screening detection programs began in the early
From the Stanley S. Scott Cancer Center (DVS), the Department of Medicine (DVS), and the Department of Radiology (RBL), Louisiana State University Medical Center, New Orleans, Louisiana
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1960s with the first program under the Health Insurance Plan of New York (HIP Study) that continues today. This randomized, controlled study has demonstrated significant reduced mortality from breast cancer for the woman screened.I2 The next major screening program was the Breast Cancer Detection Demonstration Project (BCDDP) sponsored by the American Cancer Society and the National Cancer Institute. This project proved that asymptomatic women could be attracted to mammography screen centers and has demonstrated the practicality of breast cancer detection. The BCDDP used 28 centers around the United States with more than 250,000 women screened for annual mammograms over a 5-year period. It was not a controlled study, and critics claimed that screening mammograms found only the breast cancers that would have been detected and treated later with the same outcome. There was also criticism that radiation exposure to women under age 50 would cause more cancers later than were found at the time of examination.I2 In 1977, a national consensus conference was held at the National Institutes of Health. The report released emphasized the cost-effectiveness of clinical mammography and screening of women over the age of 50, but the implication was that routine screening under the age of 50 was not indicated unless the woman was in the high-risk group. This report, unfortunately, caused a drop in the use of mammography, even in symptomatic women. The next technical change occurred shortly after when new filmscreen combinations were developed in conjunction with dedicated mammography equipment, which significantly reduced the breast dose for each patient to 0.25 rad or less for a screening two-view mammogram. Radiologists also improved their technique and accuracy in interpretation of mammograms, and in 1987, the American College of Radiology developed guidelines to provide accreditation of mammography facilities to improve overall acceptance of mammography. Many state legislatures provided mandatory legislation requiring insurance companies to pay for screening mammography after 1987, and then in 1988, Medicare coverage became available for screening mammography with the Catastrophic Health Act. Unfortunately, this act was subsequently repealed but would have provided a screening mammogram every 2 years for disabled eligible women between the ages of 40 and 50 years. Annual mammograms would have been covered for disabled women aged 50 to 65 and high-risk women between ages 40 and 49. Baseline screening would have been given to eligible women on a one-time basis between ages 34 and 40 years.24 In 1989, many major health agencies, including the American College of Radiology, American Medical Association, American Cancer Society, National Cancer Institute, and American Society of Internal Medicine, issued a joint statement endorsing screening mammography beginning at age 40 for asymptomatic women. The data from the HIP Study of New York was reviewed and demonstrated a 25% reduction in mortality in women who had been screened in their 40s.
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The American Cancer Society established mammography guidelines (in conjunction with the American College of Radiology) in 1989 that recommended a baseline mammogram between the ages 35 and 39 years, mammography at 2-year intervals between 40 and 49, and mammography on an annual basis at age 50 and over. Mammography was also recommended annually for women between ages 40 and 49 in a high-risk group (primary maternal relative with breast cancer). Screening mammography can be performed at a variety of sites, both fixed and mobile vans. Each facility should have dedicated mammography equipment and a dedicated mammography processor. The technologist must be registered by the American Registry of Radiologic Technologists and certified as a subspecialist in mammography. The radiologist interpreting the examinations should be certified by the American College of Radiology and have subspecialty training in mammography as well as continuing education courses yearly. Food and Drug Administration standards for mammography accreditation must be met as of October 1, 1994, if a facility continues to perform mammography. These standards include quality-control programs for processor maintenance, clinical images, and phantom images. Follow-up procedures and patient recall must be available. Film retention and outcome data collection are necessary for proper patient care. The radiation dose to the patient must be monitored regularly by a certified radiation health physicist. If quality is carefully controlled, the results of a mass screening program can be maintained indefinitely and improve over time.5 Mammography screening benefits women 65 years and older because the efficacy of screening in the younger-group women (50 to 64 years) has already been proven. It also benefits women between 40 and 49 because statistics in the ACX Bulletin4 showed a breast cancer death rate drop from 1989 to 1992 in all age groups: 30 to 39 years, 8.7%; 40 to 49 years, 8.1%; 50 to 59 years, 9.3%; 60 to 69 years, 4.8%; 70 to 79 years, 3.4%; and 80 to 89 years, 1%. The controversies raised over the benefits of screening mammography have been discussed in many forms, including professional journals, newspapers, and television. Because breast cancer incidence is much lower in women aged 40 to 49 years, a much larger study group is needed, on the scale of 500,000, to have valid statistics comparable to the studies already done for women 50 to 59 years.1° Randomized clinical trials must be carried out beyond 15 to 20 years to validate results and demonstrate that screening mammography benefits women 40 to 49 years of age, as it has done in women 50 to 59 years already. The preponderance of data suggests a definite benefit that outweighs the risk for women aged 40 to 49 years and a trend toward reduced mortality from early detected breast cancers in asymptomatic women. Randomized, controlled trials, although not optimized for screening women 40 to 49 years, still demonstrated a mortality reduction that began 5 to 7 years after screening began for this group. Mammographic detection of breast tumors precedes clinical detection by 2 to 4
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years. The National Cancer Institute's own data show that there is a recent decrease in breast cancer deaths in women under 50 years, and they acknowledge that this is due in part to early detection. The BCDDP has shown that mammography is as capable of detecting early-stage breast cancers in younger women as in older women.'j The number of cases of breast cancer being diagnosed between ages 40 and 49 years is rapidly approaching the number of cases of women aged 50 to 59 years, and yet the estimate of years of life lost to breast cancer in younger women is 40% higher than in the older group. The National Breast Screening Study of Canada (NBSSC) has been analyzed and evaluated by many mammographers, and the consensus opinion is that poor mammography combined with poor interpretation leads to reduced effectiveness in mammography screening. The quality of mammography in the United States under the American College of Radiology and Food and Drug Administration guidelines results in increased accuracy in diagnosis of early breast cancers in all age groups of women. Earlier detection results in improved prognosis and decreases current mortality rates even f ~ r t h e r . ~ Newer modalities under investigation at this time are magnetic resonance (MR) imaging and digital mammography. MR imaging mammography has been used with gadolinium-DTPA contrast media and specialized pulse sequences to improve screening potential. The disadvantages of the modality are the increased number of false-positive results owing to the increased sensitivity of MR imaging, the increased cost of this procedure, and the length of time required to perform this examination. MR imaging mammography is useful in selected roles, such as to visualize breast implant rupture, searching for breast tumors in dense breasts, and finding multiple foci of cancer. At this time, MR imaging mammography is undergoing clinical trials, and it is hoped specificity for cancer will become more precise to differentiate benign from malignant breast masses. As a screening modality, it is of limited use at this time. Digital mammography has great potential and is currently undergoing clinical trials. It enhances screening mammography capability by using image manipulation to improve diagnostic accuracy and detection of smaller cancers. Screening mammography for all women between ages 40 and 64 is the best tool that can be offered to detect early breast cancer and should be used to reduce breast cancer mortality.' National surveys have indicated that people perceive physicians as the mast reliable and credible source of health information. Reports show that three fourths of Americans visited their physicians in the preceding year and that Americans visit their physicians approximately five times a year.3"These visits provide physicians with several opportunities for cancer risk reduction through periodic screening and education. There is ample evidence of noncompliance, however, among most primary care physicians and their patients in screening for various common cancers as recommended by the American Cancer Society and
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23, 38, 4u, 41 The authors are not aware National Cancer Institute.”,l l . 15, 16, lY, of a study of prevailing screening patterns among physicians that has been evaluated with direct input from physicians, in addition to supporting data from patients and office records. Information obtained in this manner provides an accurate means of assessing the recommendations and ordering practices of physicians.
Patient Recruitment and Compliance
Cancer screening tests have been underused in eligible target populations.ls,20, 27, 42 Although there is a general belief among health care providers that this phenomenon has resulted from barriers that the patient may have, such as expense, discomfort, and fear of the results of the test, it appears that patients are quite willing to have screening tests if their physicians advise them to do Physician endorsement of cancer screening tests can have a powerful effect on patient participation. Women tend to participate in mammography programs with a strong
recommendation from their physicians. There is a discrepancy with regard to the frequency that physicians supposedly suggest tests and the compliance rate.17In a previous study that the authors conducted, all the physicians recommended a Papanicolaou test or mammogram to at least 75% of eligible patients.34At least 67% of patients had mammograms performed that were ordered by the physicians. Thus, it appears that, at least in an academic family practice setting, mammography participation can be increased by physicians who are motivated. The authors found that most patients were aware of breast cancer screening guidelines. Approximately 40% of eligible subjects had a mammogram, and two thirds of women older than 45 years of age had at least one or two mammograms. This rate of physician and patient compliance is relatively high compared with rates reported in other 41 st~dies.’~, Studies have demonstrated that more than 90% of middle-aged women are aware of mammography and its advantage^.'^, 38 Most of the women had access to health care, and two thirds had used it in the previous year to obtain breast examination. Lack of knowledge or access does not readily explain the relatively low rate of screening mammography among eligible women. A significant number of women (33%) between 50 and 55 years of age and 21% of women older than 55 years of age were unaware of the mammography screening recommendations. Of women older than 55 years of age, 66% were unaware of the yearly follow-up mammography recommendations. Of the women surveyed, screening mammograms had been performed at least once on 40% of women older than 40 years of age and 37% of women older than 55 years of age. Only 21.1% of women older than 55 years of age, however, appeared to have had yearly screening mammograms.
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Review of patient medical charts for number of screening mammograms ordered by physicians for study subjects for a 5-year period showed that 41.7% of women between the ages of 35 and 39 years, 54.5% of women between 40 and 44 years of age, 22.6% of women between 45 and 54 years of age, and 31.3% of women older than 55 years of age had not had a screening mammogram. However, 58.3% of women between 35 and 39 years of age, 46.5% of women between 40 and 44 years of age, 77.4% of women between 45 and 54 years of age, and 68.8% of women older than 55 years of age had a minimum of one to two mammograms ordered by their physicians and performed in the preceding 5 years. Because women see their physicians for regular visits but do not get routine mammograms, it appears that physicians could play an important role in increasing mammography screening rates. Physicians may believe that with female patients older than 65 years of age their life expectancy may not warrant routine screening. Physicians also may misjudge the acceptance of women of cancer screening tests. Barriers to screening mentioned by participants were knowledge of the screening recommendations, fear of the results, discomfort, and poor memory. A significant number of participants did not perceive themselves to be at risk of cancer. Although fear, expense, and discomfort may deter the population from engaging in cancer screening programs, there is evidence that when physicians in this study recommended cancer screening tests the patients overcame the barriers to cancer screening. A brief discussion between the family physician and patient regarding smoking cessation has been shown to be effective in increasing smoking cessation.31,35 The authors believe that even a brief recommendation by physicians would increase cancer screening compliance.
Mammography Screening Compliance Mammography use has increased as a result of increased promotional activities over the past two decades. The proportion of women 40 years old or older reporting having had at least one mammogram nearly doubled between the 1987 National Health Interview Survey and the 1990 Mammography Attitudes and Usage Study. The proportion further increased from 64% to 74% between 1990 and 1992. As more women participate in mammography screening, promotion efforts are now designed to improve adherence to guidelines for recurrent screening. Previous studies have noted increased return rates in mammography screening programs when appointments were given and reminder postcards sent to participant^.^, 26 The authors evaluated the effect a wallet-size plastic card would have on compliance for subsequent annual mammograrn~.~~ The card, which showed the participant’s screening anniversary month, was designed to be the same size as a standard credit card and to fit easily in a wallet. A calendar with the anniversary
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month noted showed when the card was placed in the wallet. The card would act as a constant reminder because the screening anniversary would always appear when the wallet was opened. An additional benefit was the durability of the plastic screening reminder card. This study showed that issuing a plastic screening credit card to screening participants increased their rate of return for subsequent screening mammograms. The return rate was remarkably consistent for both credit card groups (72.7% and 72.1%) and significantly higher than the rates of either of the groups receiving traditional encouragement and reminders (44.2% and 35.6%). The compliance rates noted for the groups receiving traditional encouragement and reminders in this study are similar to rates noted in other s t ~ d i e s 32 .~, Participants' reasons for not returning for a subsequent mammogram included the need for a referral from their physician or that they had "put off" returning. Other obstacles were forgetfulness or economics (i.e., their insurance did not cover the cost of the test). Because most participants thought it was important to have a referral from a physician for a mammogram, it is essential that physicians be aware of the breast cancer screening guidelines and encourage patients to have regular screening mammograms. The authors found that a plastic screening credit card was a successful device for increasing the rate of return for screening mammograms. The use of such a card may be effective in increasing compliance for other periodic cancer screening examinations and for periodic screening examinations for other chronic diseases. Conclusion It appears that screening mammography is certainly a value in women over age 50, and although controversy exists regarding screening of women for breast cancer under 50 years of age, the authors believe that this strategy is the most reasonable one for women 40 to 64 years of age at this time. Additionally, it is important for physicians to remember to encourage their patients to undergo cancer screening evaluation. Encouragement by physicians is an important factor in increasing cancer screening rates. BREAST SELF-EXAMINATION
The value of breast self-examination (BSE) is a controversial issue. Most studies indicate a positive association between the practice of selfexamination and earlier detection of breast cancer. The accuracy of BSE has never been compared appropriately to that of any other technique for early detection of breast cancer. Problems in comparing studies arise when the accuracy of BSE is evaluated and the competence of the selfexamination is not accounted for. Indeed one suspects that breast self-
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examination is of greatest value in early detection in women who are competently trained and who effectively execute the technique. EVALUATION OF BREAST LESIONS
Many women discover a breast lump or mass during routine selfexamination of the breasts and seek medical evaluation from a physician. Most of the masses discovered either by the patient or physician fortunately turn out to be benign.* Careful physical examination should be carried out in conjunction with a mammogram as part of the initial workup of the breast lump. The mass may fall into a benign category both by physical examination and mammography. Breast ultrasound is now available to characterize the mass further into cystic or solid lesions and, in turn, can help with the final diagnosis. Cyst aspiration may be performed by direct palpation or ultrasound-guided aspiration, if required. Finally, if the mass is solid but has benign characteristics on both mammography and ultrasound, it can be followed closely at 6month intervals with repeat mammography to ensure its stability and confirm its benign character.37 If the mass appears to be suspicious for a malignancy by physical examination, mammography, or breast ultrasound, a follow-up invasive procedure (biopsy) is necessary to obtain a tissue diagnosis of the lesion. The methods used at this time include direct biopsy of the palpated lump by a cutting needle, fine-needle aspiration to obtain cells for cytology, stereotaxic needle biopsy, or needle localization of the mass in conjunction with excisional biopsy to remove the entire mass. 2y, 36, 3y that address needle-directed breast biopsy report Most series25, that 15%to 30% of biopsy specimens are malignant, the remainder being benign pathology. Mammographic criteria that increase the likelihood of malignancy being found include the presence of a mass, an irregular density, parenchymal architectural distortion, or a cluster of microcalcifications with or without an associated mass or density. A spiculated mass with or without microcalcifications is associated with a high likelihood of discovering malignancy. A tightly clustered group of microcalcifications, with or without an associated density, must be viewed with suspicion. In general, a cluster of five or more microcalcifications within 1 cm" of breast tissue is widely accepted as an indication for biopsy. A mass that is palpated but not visualized on initial mammography should not be ignored. Breast ultrasound can define cysts or solid lesions in breast tissue when the mass is not identified on a mammogram.22 This is particularly useful in a woman who has dense fibroglandular tissue in both breasts, which can obscure visualization of a breast mass. Breast ultrasound can also be helpful in attempting to differentiate between benign and malignant masses in newer techniques, such as color Doppler ultrasound with computer assistance.21This is most effective in conjunction with mammography.
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History taking is an important part of the evaluation of the breast lump. Questions to ask the patient include the following: the length of time the lump has been present; was it discovered by patient or physician; size of the lump and its changes in regard to the patient's menstrual cycle (if she is premenopausal); and risk factors, such as family history of breast cancer among maternal relatives and ages of onset of disease, whether or not the patient is on birth control therapy or hormonal replacement therapy (if postmenopausal), age at onset of menses, and number of pregnancies.2 Physical findings are also important in evaluating the breast lump. Benign lumps may vary in consistency on physical examination from soft to rubbery to firm, usually smooth, mobile, and sometimes bilateral and symmetric. Malignant lumps tend to be hard, irregular, nonmovable or fixed, and associated with skin dimpling or nipple retraction. Sometimes a larger segment of the breast may be involved with multiple nodules, which occurs much more frequently in benign fibrocystic disease. Breast thickening owing to asymmetric fibroglandular tissue may be apparent in one breast and may be confused with a breast mass. Many women also have tenderness that develops in their breasts before the onset of menses, particularly women who have fibrocystic breast disease. These women need to be reassured that this is not usually associated with breast cancer, and they may need medical management for these symptoms. After careful history, physical examination, mammography, and ultrasound (if needed), the breast lump can be placed into the probably benign category or the probably suspicious category. The masses that fall into the probably benign category should be followed at 6-month intervals for 12 to 18 months with physical examinations, mammography, and ultrasound (if appropriate). Then, after stability has been established, yearly follow-up is sufficient. The probably suspicious masses should have fine-needle aspiration.' Other choices include stereotaxic breast biopsies, needle localization and excisional biopsy, or lumpectomy with complete excision of the palpable mass. It was previously noted that the majority of breast cancers that are not detected clinically or radiologically are in the upper outer quadrant of the breast. This is not entirely surprising in view of the fact that the upper outer quadrant of the breast is the most common site for malignan~y.~~ During the 6-month interval between follow-up mammographic examinations, some masses may disappear. This is seen in spontaneous regression of benign cysts of the breast without any intervention by a~piration.~ Solid masses that appear benign can also be followed at 6month intervals. Shape and size can be determined and measured on each evaluation. This depends on regular patient follow-up and compliance. If patients are unreliable, following probably benign breast masses becomes more of a challenge. Sometimes, benign-appearing masses are biopsied because of the uncertainty of patient follow-up on a regular, continuing basis.36,37
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Evaluation of the breast lump requires patient cooperation, prompt physical examination, and appropriate imaging studies or interventional procedures as needed. A suspicious breast lump should not be ignored or watched for a long period of time to see if it resolves. Prompt detection of breast cancer depends on early, complete evaluation whenever possible. All physicians who examine patients who present with breast lumps must act quickly and decisively to avoid delays, which could cause adverse results for the patient. The primary care physician holds the key to early diagnosis of curable breast cancer and shares this responsibility with the radiologist. Complete history and physical examination data pertaining to the breast should be included on the patient mammography request form to give the breast imager assistance in making the diagnosis. It is vital that physicians remember that breast cancers do not necessarily present in a classic way-discrete palpable mass with or without mammographic findings. Breast cancer can present as an area of thickening in the breast or indeed pain or tenderness without palpable abnormality. Although a mammogram may be helpful in ascertaining a diagnosis, its sensitivity approaches only 85% to 90% in specialized centers. Additionally, needle-directed biopsy has a similar sensitivity, and thus a negative result does not preclude a diagnosis of breast cancer. If there is any doubt in the mind of the physician as to the nature of the breast complaint, a prudent approach would be to obtain the evaluation of a surgeon who routinely evaluates this problem. References 1. Abele JS, Miller TR, Goodson WH, et al: Fine needle aspiration of palpable masses. Arch Surg 118859-863,1983 2. Brady D, Hodgkins MC, Goodson WH: The lumpy breast. West J Med 149:226-229, 1988 3. Brenner RJ, Bein ME, Sarti D, et al: Spontaneous regression of internal benign cysts of the breast. Radiology 193365-368, 1994 4. Broder S: Breast cancer death rates drop. ACR Bulletin 51:L 1995 5. Burhenne LJW, Burhenne HJ, Tran L: Quality-oriented mass mammography screening. Radiology 194:185-188, 1995 6. Cancer 72:1449-1456, 1993 7. Coll PP, O’Connor PJ, Crabtree BJ, et al: Effect of age, education, and physician advice on utilization of screening mammography. J Am Geriatr Soc 37957-962, 1989 8. Cummings KM, Funch DP, Mettling C, et al: Family physicians’ beliefs about breast cancer screening by mammography. J Fam Pract 171029-1034, 1983 9. Curpen BN, Sickles EA, Sollitto RA, et a1 The comparative value of mammographic screening for women 4049 years old versus women 50-64 years old. AJR Am J Roentgen01 164:1099-1103, 1995 10 DAgincourt L: Mammographies dispute change in NCI policy. Diagn Imag 121-128, 1993 11 Dietrich AJ, Goldberg H: Preventive content of adult primary care: Do generalists and subspecialties differ? Am J Public Health 74:223-227, 1984 12 Dodd G D Thirty years of mammography. Section I1 ACR Bulletin. 1989, pp 10-13 13 Faulk RM, Sickles EA, Sollitto RA, et al: Clinical efficacy of mammographic screening in the elderly. Radiology 94:193-197, 1995
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14. Feig SA, Hendrich RE: Mammography‘s upside outweighs possible risks. Diagn Imag 83~53-59, 1994 15. Fox S. Baum IK. Klos DS. et al: Breast cancer screenine: The underuse of mammoera” phy. Radiology 156607-611, 1985 16. Fox SA, Klos DS, Tson CV: Underuse of screening mammography by family physicians. Radiology 166:431-433, 1988 17. Fox SA, Murata PJ, Stein JA: The impact of physician compliance on screening mammography for older women. Arch Intern Med 151:50-56, 1991 18. Fox S, Tson CV, Klos DS: An intervention to increase mammography screening by residents in family practice. J Fam Pract 20:467471, 1985 19. Gold RH, Bassett LW, Fox SA: Mammography screening: Success and problems in implementing widespread use in the United States. Radiol Clin North Am 25:10391046, 1987 20. Hayward RA, Shapiro MF, Freeman HE, et al: Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 148:1177, 1988 21. Huber S, Deloune S, Knopp MV, et al: Breast tumors: Computer-assisted quantitative assessment with color Doppler U/S. Radiology 192:797-801, 1994 22. Ikeda DM: Breast ultrasonography. Lecture, National Conference on Breast Cancer, 1994, pp 253-255 23. Keller K, George E, Podell RN: Clinical breast examination and breast self-examination experience in a family practice population. J Fam Pract 11:887-893, 1980 24. Kuper R Section I1 ACR Bulletin. 1989, pp 14-15 25. Landercasper J, Gundersen SB Jr, Gundersen AL, et al: Needle localization and biopsy of nonpalpable lesions of the breast. Surg Gynecol Obstet 164:399403, 1987 26. Lane DS, Fine H L Compliance with mammography referrals: Implications for breast cancer screening. NY State J Med 83:173-176, 1983 27. Lurie N, Manning WG, Petersen C, et al: Preventive care: Do we practice what we preach? Am J Public Health 77:801, 1987 28. McLeeland R What is Breast Screening. Section I1 ACR Bulletin. 1989, pp 7-9 29. Muskett A, McGreevy JM: Screening mammography: A surgeon’s strategy for dealing with abnormal mammographic findings. Am J Surg 154:589-592, 1987 30. National Center for Health Statistics: Health, United States, 1987. DHHS Pub. No. (PHS)88-1232, Public Health Service. Washington DC, US. Government Printing Office, 1988 31. Russell MAH, Wilson C, Taylor C: The effects of general practitioners’ advice against smoking. BMJ 2:231-235, 1979 32. Schapira DV, Kumar NB, Clark RA, et al: Mammography screening credit card and compliance. Cancer 70509-512, 1992 33. Schapira DV, Martin G, Strax P: Low cost breast cancer screening. Proc Am Soc Radiol 1986 34. Schapira DV, Pamies RJ, Kumar NB, et al: Cancer screening: Knowledge, recommendations, and practices of physicians. Cancer 71:839-843, 1993 35. Schwartz JL: Review and evaluation of smoking cessation methods: The United States and Canada, 1978-1985. NIH Pub. No 87-2940. Bethesda, MD, National Cancer Institute, 1987 36. Sickles EA: Periodic mammographic follow-up of probably benign lesions: Results in 3,184 consecutive cases. Radiology 179:463-468 37. Sickles E A Non-palpable, circumscribed, non-calcified solid breast masses: Likelihood of malignancy based on lesion size and age of patient. Radiology 192439442, 1994 38. Sickles EA, Weber WN, Galvin HB, et al: Mammographic screening: How to operate successfully at low cost. Radiology 160:95-97, 1986 39. Sickle-Santanello BJ, O’Dwyer PJ, McCabe DP, et al: Needle localization of mammographically detected lesions in perspective. Am J Surg 154:279-282, 1987 40. Survey of physicians’ attitudes and practices in early cancer detection. CA 35:197213, 1985 41. Woo B, Woo 8, Cook EF, et al: Screening procedures in the asymptomatic adult: Comparisons of physicians’ recommendations, patients’ desires, published guidelines, and actual practice. JAMA 254:1480-1484, 1985 Y
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42. Zapka JG, Stoddard AM, Costanza ME, et al: Breast cancer screening by mammography: Utilization and associated factors. Am J Public Health 791499, 1989
Address reprint requests to David V. Schapira, MBChB, FRCP(C) Stanley S. Scott Cancer Center Louisiana State University Medical Center 2025 Gravier Street, Suite 622 New Orleans, LA 70112
ADDENDUM
For additional reading on this subject, the editors recommend the following: Desforges JF: Evaluation of a palpable breast mass. N Engl J Med 327937-942, 1992 Warner EA: Breast cancer screening. Prim Care 19:575-588, 1992
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BREAST CANCER SCREENING AND COMPLIANCE AND EVALUATION OF LESIONS David V. Schapira, MBChB, FRCP(C), and Richard B. Levine, MD
BREAST CANCER SCREENING AND COMPLIANCE Breast Cancer Screening Studies and Guidelines
Screening mammography is the term used to define an attempt to detect unsuspected breast cancer in asymptomatic women.28This screening mammogram may be referred from another physician or can be selfreferred by the patient herself. Screening mammography programs are designed to reach large numbers of women so that examinations may be done quickly, usually without physician supervision on site, processed either on site or in a central location, and then batch read by the radiologist at one location to separate the normal from the abnormal mammogram. This process also keeps the costs reasonable to the patient and encourages increased use. Screening mammography is incomplete without a physical examination, which may be done by the referring physician or the radiologist depending on the physical setup at the mammography facility. The woman who is self-referred must be willing to be referred to another physician for follow-up care in the case of an abnormal mammogram. The selection of this physician may be guided by the radiologist depending on the problem to be dealt with. Historically, breast screening detection programs began in the early
From the Stanley S. Scott Cancer Center (DVS), the Department of Medicine (DVS), and the Department of Radiology (RBL), Louisiana State University Medical Center, New Orleans, Louisiana
MEDICAL CLINICS OF NORTH AMERICA VOLUME 80 * NUMBER 1 * JANUARY 1996
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1960s with the first program under the Health Insurance Plan of New York (HIP Study) that continues today. This randomized, controlled study has demonstrated significant reduced mortality from breast cancer for the woman screened.I2 The next major screening program was the Breast Cancer Detection Demonstration Project (BCDDP) sponsored by the American Cancer Society and the National Cancer Institute. This project proved that asymptomatic women could be attracted to mammography screen centers and has demonstrated the practicality of breast cancer detection. The BCDDP used 28 centers around the United States with more than 250,000 women screened for annual mammograms over a 5-year period. It was not a controlled study, and critics claimed that screening mammograms found only the breast cancers that would have been detected and treated later with the same outcome. There was also criticism that radiation exposure to women under age 50 would cause more cancers later than were found at the time of examination.I2 In 1977, a national consensus conference was held at the National Institutes of Health. The report released emphasized the cost-effectiveness of clinical mammography and screening of women over the age of 50, but the implication was that routine screening under the age of 50 was not indicated unless the woman was in the high-risk group. This report, unfortunately, caused a drop in the use of mammography, even in symptomatic women. The next technical change occurred shortly after when new filmscreen combinations were developed in conjunction with dedicated mammography equipment, which significantly reduced the breast dose for each patient to 0.25 rad or less for a screening two-view mammogram. Radiologists also improved their technique and accuracy in interpretation of mammograms, and in 1987, the American College of Radiology developed guidelines to provide accreditation of mammography facilities to improve overall acceptance of mammography. Many state legislatures provided mandatory legislation requiring insurance companies to pay for screening mammography after 1987, and then in 1988, Medicare coverage became available for screening mammography with the Catastrophic Health Act. Unfortunately, this act was subsequently repealed but would have provided a screening mammogram every 2 years for disabled eligible women between the ages of 40 and 50 years. Annual mammograms would have been covered for disabled women aged 50 to 65 and high-risk women between ages 40 and 49. Baseline screening would have been given to eligible women on a one-time basis between ages 34 and 40 years.24 In 1989, many major health agencies, including the American College of Radiology, American Medical Association, American Cancer Society, National Cancer Institute, and American Society of Internal Medicine, issued a joint statement endorsing screening mammography beginning at age 40 for asymptomatic women. The data from the HIP Study of New York was reviewed and demonstrated a 25% reduction in mortality in women who had been screened in their 40s.
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The American Cancer Society established mammography guidelines (in conjunction with the American College of Radiology) in 1989 that recommended a baseline mammogram between the ages 35 and 39 years, mammography at 2-year intervals between 40 and 49, and mammography on an annual basis at age 50 and over. Mammography was also recommended annually for women between ages 40 and 49 in a high-risk group (primary maternal relative with breast cancer). Screening mammography can be performed at a variety of sites, both fixed and mobile vans. Each facility should have dedicated mammography equipment and a dedicated mammography processor. The technologist must be registered by the American Registry of Radiologic Technologists and certified as a subspecialist in mammography. The radiologist interpreting the examinations should be certified by the American College of Radiology and have subspecialty training in mammography as well as continuing education courses yearly. Food and Drug Administration standards for mammography accreditation must be met as of October 1, 1994, if a facility continues to perform mammography. These standards include quality-control programs for processor maintenance, clinical images, and phantom images. Follow-up procedures and patient recall must be available. Film retention and outcome data collection are necessary for proper patient care. The radiation dose to the patient must be monitored regularly by a certified radiation health physicist. If quality is carefully controlled, the results of a mass screening program can be maintained indefinitely and improve over time.5 Mammography screening benefits women 65 years and older because the efficacy of screening in the younger-group women (50 to 64 years) has already been proven. It also benefits women between 40 and 49 because statistics in the ACX Bulletin4 showed a breast cancer death rate drop from 1989 to 1992 in all age groups: 30 to 39 years, 8.7%; 40 to 49 years, 8.1%; 50 to 59 years, 9.3%; 60 to 69 years, 4.8%; 70 to 79 years, 3.4%; and 80 to 89 years, 1%. The controversies raised over the benefits of screening mammography have been discussed in many forms, including professional journals, newspapers, and television. Because breast cancer incidence is much lower in women aged 40 to 49 years, a much larger study group is needed, on the scale of 500,000, to have valid statistics comparable to the studies already done for women 50 to 59 years.1° Randomized clinical trials must be carried out beyond 15 to 20 years to validate results and demonstrate that screening mammography benefits women 40 to 49 years of age, as it has done in women 50 to 59 years already. The preponderance of data suggests a definite benefit that outweighs the risk for women aged 40 to 49 years and a trend toward reduced mortality from early detected breast cancers in asymptomatic women. Randomized, controlled trials, although not optimized for screening women 40 to 49 years, still demonstrated a mortality reduction that began 5 to 7 years after screening began for this group. Mammographic detection of breast tumors precedes clinical detection by 2 to 4
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years. The National Cancer Institute's own data show that there is a recent decrease in breast cancer deaths in women under 50 years, and they acknowledge that this is due in part to early detection. The BCDDP has shown that mammography is as capable of detecting early-stage breast cancers in younger women as in older women.'j The number of cases of breast cancer being diagnosed between ages 40 and 49 years is rapidly approaching the number of cases of women aged 50 to 59 years, and yet the estimate of years of life lost to breast cancer in younger women is 40% higher than in the older group. The National Breast Screening Study of Canada (NBSSC) has been analyzed and evaluated by many mammographers, and the consensus opinion is that poor mammography combined with poor interpretation leads to reduced effectiveness in mammography screening. The quality of mammography in the United States under the American College of Radiology and Food and Drug Administration guidelines results in increased accuracy in diagnosis of early breast cancers in all age groups of women. Earlier detection results in improved prognosis and decreases current mortality rates even f ~ r t h e r . ~ Newer modalities under investigation at this time are magnetic resonance (MR) imaging and digital mammography. MR imaging mammography has been used with gadolinium-DTPA contrast media and specialized pulse sequences to improve screening potential. The disadvantages of the modality are the increased number of false-positive results owing to the increased sensitivity of MR imaging, the increased cost of this procedure, and the length of time required to perform this examination. MR imaging mammography is useful in selected roles, such as to visualize breast implant rupture, searching for breast tumors in dense breasts, and finding multiple foci of cancer. At this time, MR imaging mammography is undergoing clinical trials, and it is hoped specificity for cancer will become more precise to differentiate benign from malignant breast masses. As a screening modality, it is of limited use at this time. Digital mammography has great potential and is currently undergoing clinical trials. It enhances screening mammography capability by using image manipulation to improve diagnostic accuracy and detection of smaller cancers. Screening mammography for all women between ages 40 and 64 is the best tool that can be offered to detect early breast cancer and should be used to reduce breast cancer mortality.' National surveys have indicated that people perceive physicians as the mast reliable and credible source of health information. Reports show that three fourths of Americans visited their physicians in the preceding year and that Americans visit their physicians approximately five times a year.3"These visits provide physicians with several opportunities for cancer risk reduction through periodic screening and education. There is ample evidence of noncompliance, however, among most primary care physicians and their patients in screening for various common cancers as recommended by the American Cancer Society and
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23, 38, 4u, 41 The authors are not aware National Cancer Institute.”,l l . 15, 16, lY, of a study of prevailing screening patterns among physicians that has been evaluated with direct input from physicians, in addition to supporting data from patients and office records. Information obtained in this manner provides an accurate means of assessing the recommendations and ordering practices of physicians.
Patient Recruitment and Compliance
Cancer screening tests have been underused in eligible target populations.ls,20, 27, 42 Although there is a general belief among health care providers that this phenomenon has resulted from barriers that the patient may have, such as expense, discomfort, and fear of the results of the test, it appears that patients are quite willing to have screening tests if their physicians advise them to do Physician endorsement of cancer screening tests can have a powerful effect on patient participation. Women tend to participate in mammography programs with a strong
recommendation from their physicians. There is a discrepancy with regard to the frequency that physicians supposedly suggest tests and the compliance rate.17In a previous study that the authors conducted, all the physicians recommended a Papanicolaou test or mammogram to at least 75% of eligible patients.34At least 67% of patients had mammograms performed that were ordered by the physicians. Thus, it appears that, at least in an academic family practice setting, mammography participation can be increased by physicians who are motivated. The authors found that most patients were aware of breast cancer screening guidelines. Approximately 40% of eligible subjects had a mammogram, and two thirds of women older than 45 years of age had at least one or two mammograms. This rate of physician and patient compliance is relatively high compared with rates reported in other 41 st~dies.’~, Studies have demonstrated that more than 90% of middle-aged women are aware of mammography and its advantage^.'^, 38 Most of the women had access to health care, and two thirds had used it in the previous year to obtain breast examination. Lack of knowledge or access does not readily explain the relatively low rate of screening mammography among eligible women. A significant number of women (33%) between 50 and 55 years of age and 21% of women older than 55 years of age were unaware of the mammography screening recommendations. Of women older than 55 years of age, 66% were unaware of the yearly follow-up mammography recommendations. Of the women surveyed, screening mammograms had been performed at least once on 40% of women older than 40 years of age and 37% of women older than 55 years of age. Only 21.1% of women older than 55 years of age, however, appeared to have had yearly screening mammograms.
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Review of patient medical charts for number of screening mammograms ordered by physicians for study subjects for a 5-year period showed that 41.7% of women between the ages of 35 and 39 years, 54.5% of women between 40 and 44 years of age, 22.6% of women between 45 and 54 years of age, and 31.3% of women older than 55 years of age had not had a screening mammogram. However, 58.3% of women between 35 and 39 years of age, 46.5% of women between 40 and 44 years of age, 77.4% of women between 45 and 54 years of age, and 68.8% of women older than 55 years of age had a minimum of one to two mammograms ordered by their physicians and performed in the preceding 5 years. Because women see their physicians for regular visits but do not get routine mammograms, it appears that physicians could play an important role in increasing mammography screening rates. Physicians may believe that with female patients older than 65 years of age their life expectancy may not warrant routine screening. Physicians also may misjudge the acceptance of women of cancer screening tests. Barriers to screening mentioned by participants were knowledge of the screening recommendations, fear of the results, discomfort, and poor memory. A significant number of participants did not perceive themselves to be at risk of cancer. Although fear, expense, and discomfort may deter the population from engaging in cancer screening programs, there is evidence that when physicians in this study recommended cancer screening tests the patients overcame the barriers to cancer screening. A brief discussion between the family physician and patient regarding smoking cessation has been shown to be effective in increasing smoking cessation.31,35 The authors believe that even a brief recommendation by physicians would increase cancer screening compliance.
Mammography Screening Compliance Mammography use has increased as a result of increased promotional activities over the past two decades. The proportion of women 40 years old or older reporting having had at least one mammogram nearly doubled between the 1987 National Health Interview Survey and the 1990 Mammography Attitudes and Usage Study. The proportion further increased from 64% to 74% between 1990 and 1992. As more women participate in mammography screening, promotion efforts are now designed to improve adherence to guidelines for recurrent screening. Previous studies have noted increased return rates in mammography screening programs when appointments were given and reminder postcards sent to participant^.^, 26 The authors evaluated the effect a wallet-size plastic card would have on compliance for subsequent annual mammograrn~.~~ The card, which showed the participant’s screening anniversary month, was designed to be the same size as a standard credit card and to fit easily in a wallet. A calendar with the anniversary
BREAST CANCER SCREENING AND COMPLIANCE AND EVALUATION OF LESIONS
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month noted showed when the card was placed in the wallet. The card would act as a constant reminder because the screening anniversary would always appear when the wallet was opened. An additional benefit was the durability of the plastic screening reminder card. This study showed that issuing a plastic screening credit card to screening participants increased their rate of return for subsequent screening mammograms. The return rate was remarkably consistent for both credit card groups (72.7% and 72.1%) and significantly higher than the rates of either of the groups receiving traditional encouragement and reminders (44.2% and 35.6%). The compliance rates noted for the groups receiving traditional encouragement and reminders in this study are similar to rates noted in other s t ~ d i e s 32 .~, Participants' reasons for not returning for a subsequent mammogram included the need for a referral from their physician or that they had "put off" returning. Other obstacles were forgetfulness or economics (i.e., their insurance did not cover the cost of the test). Because most participants thought it was important to have a referral from a physician for a mammogram, it is essential that physicians be aware of the breast cancer screening guidelines and encourage patients to have regular screening mammograms. The authors found that a plastic screening credit card was a successful device for increasing the rate of return for screening mammograms. The use of such a card may be effective in increasing compliance for other periodic cancer screening examinations and for periodic screening examinations for other chronic diseases. Conclusion It appears that screening mammography is certainly a value in women over age 50, and although controversy exists regarding screening of women for breast cancer under 50 years of age, the authors believe that this strategy is the most reasonable one for women 40 to 64 years of age at this time. Additionally, it is important for physicians to remember to encourage their patients to undergo cancer screening evaluation. Encouragement by physicians is an important factor in increasing cancer screening rates. BREAST SELF-EXAMINATION
The value of breast self-examination (BSE) is a controversial issue. Most studies indicate a positive association between the practice of selfexamination and earlier detection of breast cancer. The accuracy of BSE has never been compared appropriately to that of any other technique for early detection of breast cancer. Problems in comparing studies arise when the accuracy of BSE is evaluated and the competence of the selfexamination is not accounted for. Indeed one suspects that breast self-
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examination is of greatest value in early detection in women who are competently trained and who effectively execute the technique. EVALUATION OF BREAST LESIONS
Many women discover a breast lump or mass during routine selfexamination of the breasts and seek medical evaluation from a physician. Most of the masses discovered either by the patient or physician fortunately turn out to be benign.* Careful physical examination should be carried out in conjunction with a mammogram as part of the initial workup of the breast lump. The mass may fall into a benign category both by physical examination and mammography. Breast ultrasound is now available to characterize the mass further into cystic or solid lesions and, in turn, can help with the final diagnosis. Cyst aspiration may be performed by direct palpation or ultrasound-guided aspiration, if required. Finally, if the mass is solid but has benign characteristics on both mammography and ultrasound, it can be followed closely at 6month intervals with repeat mammography to ensure its stability and confirm its benign character.37 If the mass appears to be suspicious for a malignancy by physical examination, mammography, or breast ultrasound, a follow-up invasive procedure (biopsy) is necessary to obtain a tissue diagnosis of the lesion. The methods used at this time include direct biopsy of the palpated lump by a cutting needle, fine-needle aspiration to obtain cells for cytology, stereotaxic needle biopsy, or needle localization of the mass in conjunction with excisional biopsy to remove the entire mass. 2y, 36, 3y that address needle-directed breast biopsy report Most series25, that 15%to 30% of biopsy specimens are malignant, the remainder being benign pathology. Mammographic criteria that increase the likelihood of malignancy being found include the presence of a mass, an irregular density, parenchymal architectural distortion, or a cluster of microcalcifications with or without an associated mass or density. A spiculated mass with or without microcalcifications is associated with a high likelihood of discovering malignancy. A tightly clustered group of microcalcifications, with or without an associated density, must be viewed with suspicion. In general, a cluster of five or more microcalcifications within 1 cm" of breast tissue is widely accepted as an indication for biopsy. A mass that is palpated but not visualized on initial mammography should not be ignored. Breast ultrasound can define cysts or solid lesions in breast tissue when the mass is not identified on a mammogram.22 This is particularly useful in a woman who has dense fibroglandular tissue in both breasts, which can obscure visualization of a breast mass. Breast ultrasound can also be helpful in attempting to differentiate between benign and malignant masses in newer techniques, such as color Doppler ultrasound with computer assistance.21This is most effective in conjunction with mammography.
BREAST CANCER SCREENING AND COMPLIANCE AND EVALUATION OF LESIONS
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History taking is an important part of the evaluation of the breast lump. Questions to ask the patient include the following: the length of time the lump has been present; was it discovered by patient or physician; size of the lump and its changes in regard to the patient's menstrual cycle (if she is premenopausal); and risk factors, such as family history of breast cancer among maternal relatives and ages of onset of disease, whether or not the patient is on birth control therapy or hormonal replacement therapy (if postmenopausal), age at onset of menses, and number of pregnancies.2 Physical findings are also important in evaluating the breast lump. Benign lumps may vary in consistency on physical examination from soft to rubbery to firm, usually smooth, mobile, and sometimes bilateral and symmetric. Malignant lumps tend to be hard, irregular, nonmovable or fixed, and associated with skin dimpling or nipple retraction. Sometimes a larger segment of the breast may be involved with multiple nodules, which occurs much more frequently in benign fibrocystic disease. Breast thickening owing to asymmetric fibroglandular tissue may be apparent in one breast and may be confused with a breast mass. Many women also have tenderness that develops in their breasts before the onset of menses, particularly women who have fibrocystic breast disease. These women need to be reassured that this is not usually associated with breast cancer, and they may need medical management for these symptoms. After careful history, physical examination, mammography, and ultrasound (if needed), the breast lump can be placed into the probably benign category or the probably suspicious category. The masses that fall into the probably benign category should be followed at 6-month intervals for 12 to 18 months with physical examinations, mammography, and ultrasound (if appropriate). Then, after stability has been established, yearly follow-up is sufficient. The probably suspicious masses should have fine-needle aspiration.' Other choices include stereotaxic breast biopsies, needle localization and excisional biopsy, or lumpectomy with complete excision of the palpable mass. It was previously noted that the majority of breast cancers that are not detected clinically or radiologically are in the upper outer quadrant of the breast. This is not entirely surprising in view of the fact that the upper outer quadrant of the breast is the most common site for malignan~y.~~ During the 6-month interval between follow-up mammographic examinations, some masses may disappear. This is seen in spontaneous regression of benign cysts of the breast without any intervention by a~piration.~ Solid masses that appear benign can also be followed at 6month intervals. Shape and size can be determined and measured on each evaluation. This depends on regular patient follow-up and compliance. If patients are unreliable, following probably benign breast masses becomes more of a challenge. Sometimes, benign-appearing masses are biopsied because of the uncertainty of patient follow-up on a regular, continuing basis.36,37
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Evaluation of the breast lump requires patient cooperation, prompt physical examination, and appropriate imaging studies or interventional procedures as needed. A suspicious breast lump should not be ignored or watched for a long period of time to see if it resolves. Prompt detection of breast cancer depends on early, complete evaluation whenever possible. All physicians who examine patients who present with breast lumps must act quickly and decisively to avoid delays, which could cause adverse results for the patient. The primary care physician holds the key to early diagnosis of curable breast cancer and shares this responsibility with the radiologist. Complete history and physical examination data pertaining to the breast should be included on the patient mammography request form to give the breast imager assistance in making the diagnosis. It is vital that physicians remember that breast cancers do not necessarily present in a classic way-discrete palpable mass with or without mammographic findings. Breast cancer can present as an area of thickening in the breast or indeed pain or tenderness without palpable abnormality. Although a mammogram may be helpful in ascertaining a diagnosis, its sensitivity approaches only 85% to 90% in specialized centers. Additionally, needle-directed biopsy has a similar sensitivity, and thus a negative result does not preclude a diagnosis of breast cancer. If there is any doubt in the mind of the physician as to the nature of the breast complaint, a prudent approach would be to obtain the evaluation of a surgeon who routinely evaluates this problem. References 1. Abele JS, Miller TR, Goodson WH, et al: Fine needle aspiration of palpable masses. Arch Surg 118859-863,1983 2. Brady D, Hodgkins MC, Goodson WH: The lumpy breast. West J Med 149:226-229, 1988 3. Brenner RJ, Bein ME, Sarti D, et al: Spontaneous regression of internal benign cysts of the breast. Radiology 193365-368, 1994 4. Broder S: Breast cancer death rates drop. ACR Bulletin 51:L 1995 5. Burhenne LJW, Burhenne HJ, Tran L: Quality-oriented mass mammography screening. Radiology 194:185-188, 1995 6. Cancer 72:1449-1456, 1993 7. Coll PP, O’Connor PJ, Crabtree BJ, et al: Effect of age, education, and physician advice on utilization of screening mammography. J Am Geriatr Soc 37957-962, 1989 8. Cummings KM, Funch DP, Mettling C, et al: Family physicians’ beliefs about breast cancer screening by mammography. J Fam Pract 171029-1034, 1983 9. Curpen BN, Sickles EA, Sollitto RA, et a1 The comparative value of mammographic screening for women 4049 years old versus women 50-64 years old. AJR Am J Roentgen01 164:1099-1103, 1995 10 DAgincourt L: Mammographies dispute change in NCI policy. Diagn Imag 121-128, 1993 11 Dietrich AJ, Goldberg H: Preventive content of adult primary care: Do generalists and subspecialties differ? Am J Public Health 74:223-227, 1984 12 Dodd G D Thirty years of mammography. Section I1 ACR Bulletin. 1989, pp 10-13 13 Faulk RM, Sickles EA, Sollitto RA, et al: Clinical efficacy of mammographic screening in the elderly. Radiology 94:193-197, 1995
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14. Feig SA, Hendrich RE: Mammography‘s upside outweighs possible risks. Diagn Imag 83~53-59, 1994 15. Fox S. Baum IK. Klos DS. et al: Breast cancer screenine: The underuse of mammoera” phy. Radiology 156607-611, 1985 16. Fox SA, Klos DS, Tson CV: Underuse of screening mammography by family physicians. Radiology 166:431-433, 1988 17. Fox SA, Murata PJ, Stein JA: The impact of physician compliance on screening mammography for older women. Arch Intern Med 151:50-56, 1991 18. Fox S, Tson CV, Klos DS: An intervention to increase mammography screening by residents in family practice. J Fam Pract 20:467471, 1985 19. Gold RH, Bassett LW, Fox SA: Mammography screening: Success and problems in implementing widespread use in the United States. Radiol Clin North Am 25:10391046, 1987 20. Hayward RA, Shapiro MF, Freeman HE, et al: Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 148:1177, 1988 21. Huber S, Deloune S, Knopp MV, et al: Breast tumors: Computer-assisted quantitative assessment with color Doppler U/S. Radiology 192:797-801, 1994 22. Ikeda DM: Breast ultrasonography. Lecture, National Conference on Breast Cancer, 1994, pp 253-255 23. Keller K, George E, Podell RN: Clinical breast examination and breast self-examination experience in a family practice population. J Fam Pract 11:887-893, 1980 24. Kuper R Section I1 ACR Bulletin. 1989, pp 14-15 25. Landercasper J, Gundersen SB Jr, Gundersen AL, et al: Needle localization and biopsy of nonpalpable lesions of the breast. Surg Gynecol Obstet 164:399403, 1987 26. Lane DS, Fine H L Compliance with mammography referrals: Implications for breast cancer screening. NY State J Med 83:173-176, 1983 27. Lurie N, Manning WG, Petersen C, et al: Preventive care: Do we practice what we preach? Am J Public Health 77:801, 1987 28. McLeeland R What is Breast Screening. Section I1 ACR Bulletin. 1989, pp 7-9 29. Muskett A, McGreevy JM: Screening mammography: A surgeon’s strategy for dealing with abnormal mammographic findings. Am J Surg 154:589-592, 1987 30. National Center for Health Statistics: Health, United States, 1987. DHHS Pub. No. (PHS)88-1232, Public Health Service. Washington DC, US. Government Printing Office, 1988 31. Russell MAH, Wilson C, Taylor C: The effects of general practitioners’ advice against smoking. BMJ 2:231-235, 1979 32. Schapira DV, Kumar NB, Clark RA, et al: Mammography screening credit card and compliance. Cancer 70509-512, 1992 33. Schapira DV, Martin G, Strax P: Low cost breast cancer screening. Proc Am Soc Radiol 1986 34. Schapira DV, Pamies RJ, Kumar NB, et al: Cancer screening: Knowledge, recommendations, and practices of physicians. Cancer 71:839-843, 1993 35. Schwartz JL: Review and evaluation of smoking cessation methods: The United States and Canada, 1978-1985. NIH Pub. No 87-2940. Bethesda, MD, National Cancer Institute, 1987 36. Sickles EA: Periodic mammographic follow-up of probably benign lesions: Results in 3,184 consecutive cases. Radiology 179:463-468 37. Sickles E A Non-palpable, circumscribed, non-calcified solid breast masses: Likelihood of malignancy based on lesion size and age of patient. Radiology 192439442, 1994 38. Sickles EA, Weber WN, Galvin HB, et al: Mammographic screening: How to operate successfully at low cost. Radiology 160:95-97, 1986 39. Sickle-Santanello BJ, O’Dwyer PJ, McCabe DP, et al: Needle localization of mammographically detected lesions in perspective. Am J Surg 154:279-282, 1987 40. Survey of physicians’ attitudes and practices in early cancer detection. CA 35:197213, 1985 41. Woo B, Woo 8, Cook EF, et al: Screening procedures in the asymptomatic adult: Comparisons of physicians’ recommendations, patients’ desires, published guidelines, and actual practice. JAMA 254:1480-1484, 1985 Y
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42. Zapka JG, Stoddard AM, Costanza ME, et al: Breast cancer screening by mammography: Utilization and associated factors. Am J Public Health 791499, 1989
Address reprint requests to David V. Schapira, MBChB, FRCP(C) Stanley S. Scott Cancer Center Louisiana State University Medical Center 2025 Gravier Street, Suite 622 New Orleans, LA 70112
ADDENDUM
For additional reading on this subject, the editors recommend the following: Desforges JF: Evaluation of a palpable breast mass. N Engl J Med 327937-942, 1992 Warner EA: Breast cancer screening. Prim Care 19:575-588, 1992