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. Author manuscript; available in PMC: 2025 Apr 4.
Published in final edited form as: Ann Intern Med. 2024 Sep 3;177(10):1297–1307. doi: 10.7326/M24-0123

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

Diana L Miglioretti 1,2, Linn Abraham 2, Brian L Sprague 3, Christoph I Lee 4, Michael C S Bissell 5, Thao-Quyen H Ho 6, Erin J A Bowles 2, Louise M Henderson 7, Rebecca A Hubbard 8, Anna N A Tosteson 9, Karla Kerlikowske 10
PMCID: PMC11970968  NIHMSID: NIHMS2065482  PMID: 39222505

Abstract

Background.

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

Objective:

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

Design:

Cohort study.

Setting:

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

Patients:

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

Measurements:

Mammography results (true-negative or false-positive recall with recommendation for immediate additional imaging only, short-interval follow-up, or biopsy) from one or two screens. Absolute differences in the probability of returning for screening within 9–30 months of false-positive vs. true-negative screen were estimated adjusting for race, ethnicity, age, time since last mammogram, BCSC registry, and clustering within women and facility.

Results:

Women were more likely to return following a true-negative result (76.9%; 95% CI=75.1% to 78.6%) compared with a false-positive recall for additional imaging only (adjusted absolute difference=−1.9%; 95% CI=−3.1% to −0.7%), short-interval follow-up (−15.9%; 95% CI=−19.7% to −12.0%), or biopsy (−10.0; 95% CI=−14.2% to −5.9%). Asian and Hispanic/Latinx women experienced the largest decreases in the probability of returning following recommendations for short-interval follow-up (−20% to −25%) or biopsy (−13% to −14%) vs. a true-negative. Among women with two screens within 5 years, a false-positive result on the second screen was associated with a decreased probability of returning for a third screen regardless of the first screen result.

Limitations:

Women could receive care at non-BCSC facilities.

Conclusions:

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

Primary funding source:

National Cancer Institute

Keywords: breast cancer screening, false-positive mammogram, screening harms, Breast Cancer Surveillance Consortium

Introduction

Early detection of breast cancer through screening is the main secondary prevention approach to decrease breast cancer morbidity and mortality. However, screening mammography is also associated with potential harms including false-positive results that lead to additional imaging and biopsies, associated financial and opportunity costs, and patient anxiety.1–6 False-positive results are common, especially among younger women, occurring in 10–12% of screening mammograms in women ages 40–49 years.2,7 After 10 years of annual screening, 50–60% of women can expect to experience at least one false-positive recall and 7–12% at least one false-positive biopsy recommendation.7

Studies evaluating the relationship between false-positive mammography results and subsequent screening participation have contradictory results. In countries other than the U.S., two meta-analyses8,9 and several subsequent studies10–15 indicate lower re-screening rates following a false-positive versus a true-negative mammogram. In the U.S., several older studies report higher re-screening rates following a false-positive result9 while a 2017 study conducted in a large healthcare organization in Chicago found lower re-screening rates following a false-positive result.16 Most studies were published 10–20 years ago and did not evaluate results from multiple rounds of screening or by racial or ethnic group. The U.S. Preventive Services Task Force (USPSTF) recently highlighted the need for research to better understand the potential harms associated with screening,17 and identified a critical evidence gap regarding whether the balance of benefits and harms of breast cancer screening vary across racial and ethnic groups.18

Using the large and diverse Breast Cancer Surveillance Consortium (BCSC) cohort, we evaluated the association between screening mammography results (true-negative or false-positive recall for immediate additional imaging only, short interval follow-up, or biopsy) on up to two sequential screening mammograms and the probability of returning for routine screening. Associations were also evaluated by race and ethnicity, age group, and time since last mammogram.

Materials and Methods

Study Setting, Data Sources, and Participants

This report follows STROBE reporting guidelines for cohort studies.19 In this observational study, we selected all screening mammograms performed from January 1, 2005 to December 29, 2017 among women aged 40–73 years at 177 breast imaging facilities participating in six U.S.-based BCSC registries (www.bcsc-research.org): Carolina Mammography Registry, Kaiser Permanente Washington Registry, Metro Chicago Breast Cancer Registry, New Hampshire Mammography Network, Vermont Breast Cancer Surveillance System, San Francisco Mammography Registry. The upper age limit of 73 years was chosen to allow for approximately two years of follow-up, given that USPSTF guidelines have found insufficient evidence to recommend screening after age 74 years.20

For the analytic sample, we identified N=6,385,487 screening mammograms performed on women without a history of breast cancer living within the BCSC registries’ catchment areas, of which N=5,617,903 were performed on women ages 40–73 years (eFigure 1). Screens were identified using the BCSC definition based on a clinical indication of screening and excluding unilateral mammograms and mammograms preceded by a mammogram in the prior 9 months.21 We excluded N=1,637,382 screens performed after July 1, 2008 - January 1, 2018, depending on facility, to ensure at least 30-months of data collection following the screens to capture subsequent screens and breast cancer diagnoses. We excluded N=137,067 screens with a breast cancer diagnosis, death, or disenrollment from an integrated healthcare system during the 30-month follow-up period, to restrict to women who should return for subsequent screening. We excluded N=15,125 screens missing the initial or final Breast Imaging Reporting and Data System (BI-RADS) assessment because false-positive status could not be determined. We excluded N=298,504 screens missing time since last mammogram (N=174,225) or race and ethnicity (N=124,279), because our main goal was to evaluate associations by these variables; no screening mammograms were missing age. The final study cohort included 3,529,825 screening examinations in 1,053,672 women.

BCSC registries and the Statistical Coordinating Center received Institutional Review Board approval for active or passive consenting processes or a waiver of consent to enroll participants, link, and pool data, and perform analyses. Procedures were Health Insurance Portability and Accountability Act compliant, and registries and the Coordinating Center received a Federal Certificate of Confidentiality and other protections for the identities of women, physicians, and facilities.

Measures, Definitions, and Outcomes

At each screening examination, self-reported information on age, personal and first degree family history of breast cancer, race, ethnicity, time since last mammogram, height, weight, and ZIP code was obtained from questionnaires or the electronic medical record. Educational attainment by ZIP code of residence was based on the 2010 United States Decennial Census percentage of females with a high school degree and grouped into quartiles. Rural/urban classification was based on the Rural Urban Commuting Area (RUCA) codes for ZIP code of residence.22 Radiologists (N=906) reported screening mammography assessments and breast density following American College of Radiology BI-RADS terminology.23 Time since last mammogram was defined based on the most recent prior date recorded in the BCSC database and self-reported information and categorized as first mammogram, 1 year (9–18 months), 2 years (19–30 months), 3–4 years (31–59 months), and >5 years (≥60 months). Diagnoses of breast cancer (invasive carcinoma or ductal carcinoma in situ) were obtained by linkage to pathology databases and state or regional tumor registries. Deaths were obtained by linkage with state death records.

Our primary outcome was a binary indicator of return to routine screening within 9–30 months each eligible screening examination, because the USPSTF recommends biennial screening.24 Our primary exposure variable was the screening mammogram result classified as a true-negative or false-positive; false-negative and true-positive screens were not included, because we required women to be cancer free for 30 months following the screen. A true-negative result was defined as a BI-RADS initial assessment of 1 (negative) or 2 (benign). A false-positive result was defined as a BI-RADS initial assessment of 0 (needs additional imaging evaluation), 3 (probably benign), 4 (suspicious abnormality), or 5 (highly suggestive of cancer). False-positive results were further divided based on the final assessment after any imaging work-up occurring within 90 days. Final assessment was imputed for N=25,795 (0.73%) screens with a positive initial assessment but missing final assessment using a model based on exam year, age, BI-RADS density, facility, and BCSC registry. A false-positive recall with immediate additional imaging only was defined as a false-positive result with a final assessment of 1 or 2. A false-positive short-interval follow-up recommendation was defined as a false-positive result with a final BI-RADS assessment of 3. A false-positive biopsy recommendation was defined as a false-positive result with a final BI-RADS assessment of 4 or 5.

Statistical Analysis

The unit of analysis was the screening mammogram, and women may contribute multiple observations. We described the study cohort and percentages with a false-positive result by individual factors. We plotted the percentage of screens for which women returned to screening by months since screen and screen result, accounting for censoring using the Kaplan-Meier estimate. We calculated the percentage of screens for which women returned to screening within 9–30 months following the screen by screening result and individual factors.

To estimate absolute differences in the probability of returning to screening within 9–30 months with 95% confidence intervals that account for non-nested clustering among multiple mammograms performed on the same woman and/or from the same facility, we fit a linear probability model25 as a function of the screen result, race and ethnicity, age group, time since last mammogram, and BCSC registry with robust variance estimates.26,27 To assess the robustness of our results to the linear model assumption, we compared estimates from the linear probability model to those from logistic regression using a SAS macro for estimating predictive margins (%margins) that can account for correlation within only one level of clustering. The results were nearly identical when clustering on either woman or facility.

As a sensitivity analysis, we additionally adjusted for the following covariates among 1,967,997 screens in 655,188 women with no missing data: breast density, first degree family history of breast cancer, body mass index calculated as weight in kilograms divided by height in meters-squared, area-level education, and rural/urban residence. The main model was also fit subdividing by racial and ethnic group, age group, and time since last mammogram. In a secondary analysis among N=2,986,194 screens with a prior screen within 5 years (N=842,136 women), we evaluated the probability of returning for a third screen based on combinations of true-negative and false-positive results on the two screens. Differences less than 5% were considered not clinically meaningful.

Statistical analyses were performed using SAS/STAT version 14.2 (Cary, NC). Tests of statistical significance used a two-sided alpha of 0.05.

Role of funding source

This research was funded by the National Cancer Institute (P01CA154292, R01CA266377, R50CA211115). Additional support for data collection was provided by the National Institute of General Medical Sciences (U54GM115516) and by residual class settlement funds in the matter of April Krueger v. Wyeth, Inc., Case No. 03-cv-2496 (US District Court, SD of Calif.). The funders had no role in the study’s design, conduct, or reporting.

Results

The study cohort included 3,529,825 screens from 1,053,672 women (Table 1). Mean age at mammography was 55.6 (standard deviation=9.0) and most screens were performed in women who were White (71%). Most screens (64%) were performed on women who had a mammogram in the prior 18 months. Among these women, 48% had dense breasts, 16% had a first-degree family history of breast cancer, 58% were overweight or obese, half (51%) lived in ZIP codes where 91% or more of adult female residents had at least a high school education, and most (79%) lived in urban areas.

Table 1.

Characteristics of study cohort including 3,529,825 screening mammograms from 1,053,672 women, and the percentage with a false-positive result.

Study cohort of screening mammograms N (Col %) Percentage with a false-positive result (95% CI) Percentage with a false-positive recall for additional imaging only (95% CI) Percentage with a false-positive short interval follow-up recommendation (95% CI) Percentage with a false-positive biopsy recommendation (95% CI)
Total N 3,529,825 9.8% (9.1, 10.5) 5.8% (5.5, 6.2) 2.7% (2.3, 3.2) 1.3% (1.1, 1.4)
Race and ethnicity
 Asian 358,950 (10.2) 8.1% (7.2, 9.2) 5.2% (4.5, 5.8) 1.7% (1.4, 2.1) 1.3% (1.0, 1.7)
 Black/African American 384,159 (10.9) 11.7% (9.7, 14.0) 5.5% (4.9, 6.1) 4.6% (3.3, 6.5) 1.5% (1.3, 1.8)
 Hispanic/Latinx 197,164 (5.6) 10.8% (9.4, 12.4) 6.1% (5.7, 6.5) 3.5% (2.3, 5.1) 1.3% (1.1, 1.6)
 White 2,514,582 (71.2) 9.6% (9.0, 10.3) 5.9% (5.5, 6.3) 2.5% (2.2, 2.9) 1.2% (1.1, 1.3)
 Other/Multiracial 74,970 (2.1) 10.8% (10.1, 11.5) 6.4% (6.0, 6.9) 2.9% (2.5, 3.5) 1.5% (1.3, 1.7)
Age group
 40–49 years 1,031,698 (29.2) 13.0% (12.1, 13.9) 7.7% (7.2, 8.2) 3.7% (3.1, 4.4) 1.6% (1.4, 1.8)
 50–59 years 1,263,131 (35.8) 9.3% (8.7, 9.9) 5.5% (5.2, 5.8) 2.6% (2.2, 3.0) 1.2% (1.1, 1.4)
 60–69 years 980,997 (27.8) 7.7% (7.2, 8.4) 4.6% (4.4, 4.9) 2.1% (1.8, 2.5) 1.0% (0.9, 1.1)
 70–73 years 253,999 (7.2) 7.1% (6.4, 7.8) 4.2% (3.9, 4.5) 2.0% (1.6, 2.5) 0.9% (0.8, 1.0)
Time since last mammogram
 9–18 months 2,250,399 (63.8) 8.2% (7.7, 8.7) 5.2% (4.9, 5.6) 2.0% (1.7, 2.4) 1.0% (0.9, 1.1)
 19–30 months 662,628 (18.8) 8.9% (8.2, 9.6) 5.5% (5.2, 5.8) 2.3% (1.9, 2.7) 1.1% (1.0, 1.3)
 31–59 months 304,635 (8.6) 11.6% (10.9, 12.3) 6.6% (6.2, 7.0) 3.3% (2.9, 3.8) 1.7% (1.5, 1.9)
 60+ months 121,147 (3.4) 15.9% (14.9, 16.9) 8.2% (7.7, 8.7) 5.0% (4.4, 5.6) 2.7% (2.4, 3.1)
 First mammogram 191,016 (5.4) 25.0% (22.9, 27.2) 11.3% (10.4, 12.1) 10.1% (8.3, 12.3) 3.6% (3.1, 4.2)
BI-RADS breast density (Missing 11.0%)
 Almost entirely fat 308,703 (9.8) 6.0% (5.4, 6.7) 3.2% (3.0, 3.5) 1.9% (1.5, 2.4) 0.9% (0.8, 1.0)
 Scattered fibroglandular densities 1,319,963 (42.0) 9.1% (8.4, 9.9) 5.4% (5.0, 5.8) 2.6% (2.2, 3.1) 1.1% (1.0, 1.2)
 Heterogeneously dense 1,248,850 (39.8) 11.8% (10.9, 12.8) 7.0% (6.5, 7.6) 3.3% (2.8, 3.9) 1.5% (1.3, 1.7)
 Extremely dense 263,710 (8.4) 10.1% (9.3, 10.9) 6.0% (5.5, 6.5) 2.6% (2.2, 3.2) 1.5% (1.3, 1.7)
First degree family history of breast cancer (Missing 2.8%)
 No 2,885,954 (84.1) 9.7% (9.0, 10.4) 5.7% (5.4, 6.0) 2.8% (2.4, 3.3) 1.2% (1.1, 1.4)
 Yes 544,322 (15.9) 9.6% (9.0, 10.3) 5.8% (5.5, 6.2) 2.5% (2.2, 3.0) 1.3% (1.1, 1.5)
Body mass index (kg/m2) (Missing 33.6%)
 Underweight (< 18.5) 35,094 (1.5) 9.7% (9.0, 10.5) 5.8% (5.2, 6.4) 2.5% (2.1, 2.9) 1.5% (1.3, 1.7)
 Normal (18.5–24.9) 959,902 (40.9) 10.0% (9.3, 10.6) 6.3% (5.9, 6.8) 2.4% (2.1, 2.8) 1.3% (1.1, 1.5)
 Overweight (25.0–29.9) 676,873 (28.9) 10.0% (9.3, 10.8) 6.0% (5.6, 6.4) 2.8% (2.3, 3.2) 1.2% (1.1, 1.4)
 Obese I (30.0–34.9) 373,552 (15.9) 10.0% (9.2, 10.8) 5.6% (5.2, 6.0) 3.1% (2.5, 3.7) 1.3% (1.2, 1.5)
 Obese II+ (≥ 35.0) 298,946 (12.8) 9.8% (8.9, 10.9) 5.1% (4.7, 5.5) 3.3% (2.7, 4.1) 1.4% (1.3, 1.6)
Probability of high school education* (Missing 4.8%)
 < 85% 776,238 (23.1) 9.7% (8.5, 11.0) 5.3% (4.9, 5.7) 3.1% (2.3, 4.2) 1.3% (1.1, 1.5)
 85–90 878,322 (26.1) 9.5% (8.8, 10.2) 5.5% (5.1, 5.9) 2.7% (2.3, 3.2) 1.3% (1.1, 1.5)
 91–94 795,077 (23.7) 10.1% (9.3, 10.9) 6.1% (5.7, 6.6) 2.8% (2.4, 3.3) 1.2% (1.0, 1.4)
 95–100 911,047 (27.1) 9.8% (9.1, 10.5) 6.0% (5.6, 6.4) 2.5% (2.1, 3.0) 1.2% (1.1, 1.4)
Residence§ (Missing 3.6%)
 Urban 2,682,943 (78.8) 9.9% (9.1, 10.7) 5.7% (5.4, 6.0) 2.9% (2.4, 3.5) 1.3% (1.1, 1.5)
 Large rural 306,044 (9.0) 8.5% (7.2, 10.0) 5.1% (4.2, 6.2) 2.3% (1.8, 2.9) 1.1% (0.9, 1.5)
 Small rural 186,708 (5.5) 10.0% (8.4, 11.9) 6.4% (5.2, 7.8) 2.6% (1.9, 3.4) 1.1% (0.9, 1.3)
 Isolated rural 228,556 (6.7) 9.7% (8.0, 11.7) 6.1% (5.0, 7.4) 2.6% (1.8, 3.6) 1.0% (0.9, 1.2)
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CI=confidence interval

*

Based on the 2010 Census percentage of women in ZIP code with a high school degree and grouped into quartiles.

§

from Rural Urban Commuting Area (RUCA) codes for ZIP code of residence

Overall, 9.8% (95% CI=9.1% to 10.5%) of screens had a false-positive result (Table 1); 5.8% (95% CI=5.5% to 6.2%) of screens had immediate additional imaging only, 2.7% (95% CI=2.3% to 3.2%) were recommended for short-interval follow-up, and 1.3% (95% CI=1.1% to 1.4%) were recommended for biopsy. False-positive results were more common on screens performed on Black, Hispanic/Latinx, and Other/Multiracial women and less common among Asian women compared to White women. False-positive results were also more common among first mammograms and among screens on women with heterogeneously or extremely dense breasts vs. almost entirely fatty or scattered fibroglandular densities. The percentage of screens with false-positive results increased monotonically as age decreased and time since last mammogram increased. False-positive recalls requiring only immediate additional imaging were most common among Hispanic/Latinx and Other/Multiracial women; false-positive short-interval follow-up recommendations were most common among Black and Hispanic/Latinx women; and false-positive biopsy recommendations were most common among Black and Other/Multiracial women.

Figure 1 illustrates the percentage of women who returned for screening over time. Women were most likely to return after a true-negative screen, followed by a false-positive recall for additional imaging only, then a biopsy recommendation. Women were the least likely to return for screening after a short-interval follow-up recommendation. Differences persisted during the 5-year follow-up period.

Figure 1.

Figure 1.

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Percentage of women who have returned for a screening mammogram by months since screening mammogram and screening mammogram result.

Overall, 75.9% (95% CI=74.0% to 77.6%) of women returned for screening within 9–30 months of a screen and this percentage varied by screen result (Table 2). Women were most likely to return after a true-negative result (76.9%, 95% CI=75.1% to 78.6%) with a small decrease in the probability of returning after a false-positive recall with immediate additional imaging only (adjusted absolute difference=−1.9; 95% CI=−3.1 to −0.7). Women were significantly less likely to return after a false-positive short-interval follow-up or biopsy recommendation than after a true-negative result (adjusted absolute differences=−15.9, 95% CI=−19.7 to −12.0 and −10.0; 95% CI=−14.2 to −5.9, respectively). Time since last mammogram was the risk factor most strongly associated with the probability of not returning to screening within 9–30 months. Other factors examined were either not associated or weakly associated with the probability of returning (adjusted absolute differences ≤5%; Table 2 and eTable 1). Results were similar in a sensitivity analysis that adjusted for additional covariates (eTable 1).

Table 2.

Percentage who returned for a screening mammogram within 9–30 months of the screen and absolute differences by individual factors following 3,529,825 screening mammograms from 1,053,672 women.

Percentage who returned within 9–30 months (95% CI)* Unadjusted Absolute difference (95% CI)* Adjusted absolute difference (95% CI)§
Overall study cohort 75.9% (74.0, 77.6)
Current screening mammogram result
 True negative 76.9% (75.1, 78.6) ref ref
 FP recall for additional imaging only 72.4% (70.4, 74.3) −4.5 (−5.9, −3.2) −1.9 (−3.1, −0.7)
 FP SIFU recommendation 54.7% (49.9, 59.5) −22.2 (−26.7, −17.7) −15.9 (−19.7, −12.0)
 FP biopsy recommendation 61.0% (56.7, 65.0) −16.0 (−20.1, −11.8) −10.0 (−14.2, −5.9)
Race and ethnicity
 Asian 75.7% (72.0, 79.1) −1.6 (−5.1, 2.0) −0.1 (−1.9, 1.7)
 Black/African American 70.7% (66.5, 74.5) −6.6 (−10.7, −2.5) −1.7 (−4.0, 0.6)
 Hispanic/Latinx 70.3% (68.2, 72.4) −6.9 (−9.0, −4.9) −4.2 (−5.3, −3.0)
 White 77.3% (75.4, 79.0) ref ref
 Other/Multiracial 69.8% (67.5, 72.0) −7.5 (−9.2, −5.8) −4.8 (−5.9, −3.8)
Age group
 40–49 years 70.5% (68.2, 72.7) ref ref
 50–59 years 76.6% (74.7, 78.3) 6.1 (5.1, 7.1) 2.3 (1.5, 3.2)
 60–69 years 79.9% (78.1, 81.6) 9.4 (7.9, 10.9) 4.5 (3.2, 5.8)
 70–73 years 78.3% (76.4, 80.0) 7.8 (6.6, 9.0) 2.4 (1.4, 3.3)
Time since last mammogram
 9–18 months 83.8% (81.8, 85.7) ref ref
 19–30 months 71.7% (69.6, 73.7) −12.1 (−14.2, −10.0) −12.5 (−14.3, −10.8)
 31–59 months 55.8% (54.6, 56.9) −28.1 (−29.6, −26.5) −27.4 (−28.9, −26.0)
 60+ months 46.8% (44.7, 49.0) −37.0 (−39.8, −34.2) −35.5 (−38.3, −32.7)
 First mammogram 46.9% (44.9, 48.9) −36.9 (−38.7, −35.2) −35.2 (−36.4, −34.1)
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CI=confidence interval; FP=false-positive; SIFU=short-interval follow-up recommendation

*

Based on a linear probability model to estimated using generalized estimating equations to account for correlation among multiple mammograms on the same woman and/or facility.

§

Adjusted for all other variables in the table and BCSC registry.

eFigure 2 shows the unadjusted percentage of screens where women returned for screening following a false-positive or true-negative result, subdivided by racial and ethnic group, age group, and time since last mammogram. The probability of returning was generally lower for women from historically underserved racial and ethnic minority groups, increased with age regardless of screen result, and strongly decreased with increasing time since last mammogram; however, the general pattern of differences by screen result were similar regardless of racial and ethnic group, age group, and time since last mammogram.

Figure 2 shows adjusted absolute differences between the probability of returning to screening following a false-positive versus a true-negative result, subdivided by racial and ethnic group, age group, and time since last mammogram. Among all groups, decreases in the probability of returning after a false-positive recall with immediate additional imaging only vs. a true-negative result were small (<5%). Among racial and ethnic groups, Asian and Hispanic/Latinx women experienced the largest absolute decreases in the probability of returning following a false-positive recommendation for short-interval follow-up (−20% to −25%) or biopsy (−13% to −14%) vs. a true-negative result. Among time since last mammogram groups, women with a mammogram in the prior 30 months had the largest absolute decreases in the probability of returning following a false-positive recommendation for short-interval follow-up (−15% to −18%) or biopsy (−11% to −12%) vs. a true-negative result. Absolute differences were similar across age groups.

Figure 2.

Figure 2.

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Adjusted absolute differences (95% confidence intervals) between the percentage who returned for screening within 9–30 months following a false-positive versus a true negative result, by race and ethnicity, age group, and time since last mammogram. Values are from a linear probability model estimated via generalized estimating equations to account for correlation among multiple mammograms on the same woman and/or from the same facility and adjusted for race, ethnicity, age group, time since last mammogram, and BCSC registry.

Among women with two screens within 5 years, having a false-positive result on the first of the two screens was associated with a decreased probability of returning for a third screen regardless of whether the second screen was a true-negative or a false-positive (Table 3). Absolute differences in the probability of returning relative to women with a true-negative on both screens were small (<5%) for women with either a true-negative result on the second screen and any result on the first screen or with a false-positive recall with additional imaging only on the second screen and a true-negative on the first screen. Absolute differences were largest for women with a false-positive short interval follow-up (−15.7% to −24.0%) or a false-positive biopsy recommendation on the second screen (−10.6% to −15.2%), with larger differences if the first screen was also a false-positive vs. a true-negative.

Table 3.

Adjusted absolute differences (95% confidence interval) between the percentage who returned for screening within 9–30 months and screening mammogram results to restricted to 2,986,194 subsequent screening mammograms with a prior mammogram within 5 years.

Screening mammogram results N (col %) Percentage who returned for screening within 9–30 months (95% CI) Adjusted absolute differences (95% CI)
True negative on subsequent screen
 True negative on prior screen 2,489,975 (83.4) 80.4% (78.5, 82.1) ref
 FP recall with additional imaging only on prior screen 150,375 (5.0) 79.3% (77.5, 81.0) −1.6 (−2.0, −1.2)
 FP short interval follow-up recommendation prior screen 65,726 (2.2) 77.6% (75.8, 79.3) −3.3 (−4.2, −2.5)
 FP biopsy recommendation on prior screen 29,101 (1.0) 79.4% (77.3, 81.4) −1.8 (−2.7, −0.9)
FP recall on subsequent screen with additional imaging only
 True negative on prior screen 134,811 (4.5) 78.6% (76.6, 80.4) −1.4 (−2.5, −0.3)
 FP recall with additional imaging only on prior screen 14,084 (0.5) 75.4% (72.3, 78.3) −5.5 (−8.2, −2.7)
 FP short interval follow-up recommendation prior screen 6,053 (0.2) 73.3% (70.7, 75.7) −7.9 (−10.2, −5.7)
 FP biopsy recommendation on prior screen 2,447 (0.1) 74.4% (69.7, 78.5) −6.9 (−11.4, −2.3)
FP short interval follow-up recommendation on subsequent screen
 True negative on prior screen 53,307 (1.8) 63.8% (59.9, 67.6) −15.7 (−19.3, −12.2)
 FP recall for additional imaging only on prior screen 4,812 (0.2) 60.6% (56.3, 64.7) −19.1 (−23.2, −15.1)
 FP short interval follow-up recommendation prior screen 3,861 (0.1) 56.2% (50.9, 61.3) −24.0 (−28.7, −19.3)
 FP biopsy recommendation on prior screen 1,346 (<0.1) 63.1% (57.1, 68.7) −17.5 (−23.2, −11.8)
FP biopsy recommendation on subsequent screen
 True negative on prior screen 25,681 (0.9) 68.3% (63.4, 72.8) −10.6 (−15.4, −5.8)
 FP recall with additional imaging only on prior screen 2,365 (0.1) 66.3% (60.1, 71.9) −13.1 (−19.3, −7.0)
 FP short interval follow-up recommendation prior screen 1,362 (<0.1) 65.0% (61.3, 68.5) −14.1 (−18.0, −10.3)
 FP biopsy recommendation on prior screen 888 (<0.1) 64.0% (58.0, 69.5) −15.2 (−21.3, −9.1)
Open in a new tab

CI=confidence interval; FP=false-positive

*

Based on a linear probability model estimated via generalized estimating equations to account for correlation among multiple mammograms on the same woman and/or from the same facility, and adjusted for race, ethnicity, age group, time since last mammogram from subsequent screen, and BCSC registry.

Discussion

In a large, diverse cohort of 3,529,825 screening mammograms on 1,053,672 women aged 40–73 years at 177 radiology facilities in the BCSC, we found that women were less likely to return to screening after a false-positive result, especially if the recall resulted in a recommendation for short-interval follow-up or biopsy. Decreases in the probability of re-screening following a false-positive recall for immediate additional imaging only compared to a true-negative mammogram were small (<5%), with the largest decrease among those who also had a false-positive on the prior screening exam (decrease of 5.5% to 7.9% relative to those with two true-negative screens). Women were much less likely to return for screening after a false-positive short interval follow-up or biopsy recommendation regardless of the prior screening result, with absolute decreases ranging from 11% to 24% compared to those with a true-negative result.

Most prior studies did not differentiate by the type of false-positive result. Our finding that women were much less likely to return to screening after a false-positive biopsy recommendation vs. a false-positive recall for immediate additional imaging only is consistent with a study conducted in a large healthcare organization in Chicago.16 A study in Ireland found that re-screening decreased with intensity of the false-positive workup, with only 80.3% returning following a surgical biopsy compared with 90.2% following a core biopsy and 91.4% following a false-positive with no biopsy.15 The decrease in subsequent screening following a false-positive biopsy recommendation is especially concerning because having a benign biopsy is associated with an increased risk of invasive breast cancer28,29 and of advanced cancer.30 A prior BCSC study also found that women with a false-positive recall or biopsy recommendation were at increased risk of developing breast cancer for at least 10 years,31 a finding that was recently replicated in a large Swedish study.32 Healthcare providers should educate their patients about the importance of false-positive results, especially benign biopsies, and their associations with increased future breast cancer risk.

Our study indicated that women were the least likely to return for subsequent screening after a false-positive short-interval follow-up recommendation. This could be partially attributed to ACR BI-RADS clinical guidelines recommending that women undergo diagnostic imaging 6, 12, and 24 months following a short-interval follow-up recommendation.23 Consequently, these women may have been recommended to return for diagnostic mammography instead of screening mammography. However, the lower percentage who returned for screening persisted for at least 5 years after the false-positive short-interval follow-up recommendation. Women should have resumed regular screening by that time, providing further evidence that women with a short-interval follow-up recommendation are less likely to return for screening than other women.

Women with false-positive results on two sequential screening mammograms were less likely to return for another screen compared to those with one false-positive and one true-negative result. To our knowledge, the only other study to evaluate the number of false-positive results on re-screening was a Dutch study that found 93.2% (95% CI=93.1% to 93.3%) of women with a true-negative screen returned for another screen, and re-screening percentages dropped to 65.4% (95% CI=64.0%, 66.8%) for women with one prior false-positive, 56.7% (95% CI=47.1% to 66.4%) for women with two false-positives for different lesions, and 44.3% (95% CI=31.4% to 57.1%) for women with two false-positives for the same lesion.11 We were unable to determine whether false-positive results on two sequential screens were for the same or different lesions.

Survey data suggest women are more willing to be re-screened after a false-positive result, contrary to our findings based on medical records data; however, survey studies relying on self-reported data regarding screening behaviors and intentions may be subject to recall bias and selection bias (e.g., women who participate in health survey studies may be more likely to adhere to screening recommendations). In addition, surveys asked about false-positive results at any point in the past whereas we evaluated re-screening immediately following a false-positive result on the most recent or prior screen.33–36 In a national survey of 500 women, 38% reported having at least one prior false-positive mammogram and most of those women (73%) said that they now have mammograms as frequently as prior to their false-positive, 18% said they have them more frequently, and 10% less frequently.33 In a survey of 1528 mostly White women, 97% said they would likely continue screening after a false-positive result.34 In a similar survey of 911 more diverse women, 80% of Black women and 71% of Hispanic women said they would likely continue with screening after a false-positive result, compared with 93% of White women.35 We found only small differences across racial and ethnic groups in the magnitude of the decreases in the percentage who returned for subsequent screening following a false-positive vs. a true negative result, consistent with the study by Dabbous, et al.16

We did not investigate reasons that women discontinued screening. One plausible explanation is the experience was negative enough to discourage continued screening. Offering same day screening mammography interpretation and diagnostic work-up may decrease the anxiety and inconvenience associated with having to return for a second visit.37–40 In a previous BCSC study, we found that providing immediate screening mammography interpretation and same day diagnostic work-up to women without a mammogram in the prior 5 years and women ages <50 could prevent 40% of women with a positive screening mammogram from having to return for a second visit.41 Accommodating same-day screening mammography interpretation and diagnostic imaging would necessitate either an on-site radiologist or a partnership with another facility that offers same-day access for diagnostic imaging. Additionally, the length of screening mammography appointments would need to be extended to allow time for image interpretation, potential add-on diagnostic mammography and/or ultrasound, and communication of results. Another potential contributor to discontinued screening may be financial concerns. Screening services are fully covered by most health plans under the Affordable Care Act;42 however, diagnostic imaging and biopsies typically incur out-out-pocket costs, which could dissuade future screening.43–45 To address this issue, Washington State enacted legislation, effective January 1, 2024, mandating that health insurance plans cover diagnostic breast imaging examinations without any cost sharing by patients.46 A prior study found a lower probability of screening reattendance among women with a false-positive versus true-negative mammogram if their physician did not recommend screening, but no difference by screening result among women who said their physicians recommended screening.14 Another study found that women remained uncertain and concerned about their cancer status when they received unclear explanations from their physicians about the final result from diagnostic workup.6 It is important for physicians to carefully explain false-positive results to their patients, reassure them that the result was negative, and stress the importance of continued screening, especially due to increases in future risk of breast cancer associated with false-positive findings.28–32,47

Our study has several limitations. We could not capture the complete history of false-positive results over all prior screening mammograms; however, our results suggest the most recent screening result is the most important predictor of future behavior. Women could have returned to screening at a facility outside the BCSC capture area, and it is possible women with a false-positive mammogram may be more likely to switch facilities if their false-positive was associated with a negative experience. This concern is somewhat mitigated by our observed overall percentage returning to a facility within the same registry (75.9%) being comparable to the highest breast cancer screening rate reported by HEDIS over the same period (74.3%).48 We did not have information on the screening interval recommended by a woman’s healthcare providers. Although we adjusted for many potential confounding factors, we were unable to evaluate some potential confounding variables comorbidities.

In conclusion, in a large cohort of over 1 million women undergoing over 3.5 million screening mammograms, we found that women with false-positive screening results were less likely to return to screening, especially if they experienced a false-positive on two sequential screening mammograms or if the recall resulted in a short-interval follow-up or biopsy recommendation. This raises concerns about the potential unintended consequence of false-positive results on the continued participation of women in routine screening. Physicians should educate their patients about the importance of continued screening following false-positive results, especially given the associated increased future risk of breast cancer.

Supplementary Material

Supp Figure 2
Supp Table 1
Supp Figure 1

Reproducible research statement.

Study protocol:

Available upon reasonable request.

Statistical code:

Available upon reasonable request from the corresponding author.

Data set:

Available upon reasonable request from the corresponding author with appropriate regulatory approvals.

Acknowledgements:

We thank the participating women, mammography facilities, and radiologists for the data they have provided for this study. Cancer and vital status data collection was supported by several state public health departments and cancer registries (http://www.bcsc-research.org/work/acknowledgement.html).

Grant support:

This research was funded by the National Cancer Institute (P01CA154292, R01CA266377, R50CA211115). Additional support for data collection was provided by the National Institute of General Medical Sciences (U54GM115516) and by residual class settlement funds in the matter of April Krueger v. Wyeth, Inc., Case No. 03-cv-2496 (US District Court, SD of Calif.). The funders had no role in the study’s design, conduct, or reporting.

References

  • 1.Mandelblatt JS, Stout NK, Schechter CB, et al. Collaborative Modeling of the Benefits and Harms Associated With Different U.S. Breast Cancer Screening Strategies. Ann Intern Med. Feb 16 2016;164(4):215–25. doi: 10.7326/M15-1536 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Nelson HD, O’Meara ES, Kerlikowske K, Balch S, Miglioretti D. Factors Associated With Rates of False-Positive and False-Negative Results From Digital Mammography Screening: An Analysis of Registry Data. Ann Intern Med. Feb 16 2016;164(4):226–35. doi: 10.7326/M15-0971 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Brett J, Bankhead C, Henderson B, Watson E, Austoker J. The psychological impact of mammographic screening. A systematic review. Psycho-oncology. Nov 2005;14(11):917–38. doi: 10.1002/pon.904 [DOI] [PubMed] [Google Scholar]
  • 4.Brodersen J, Siersma VD. Long-term psychosocial consequences of false-positive screening mammography. Ann Fam Med. Mar-Apr 2013;11(2):106–15. doi: 10.1370/afm.1466 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Chubak J, Boudreau DM, Fishman PA, Elmore JG. Cost of breast-related care in the year following false positive screening mammograms. Med Care. Sep 2010;48(9):815–20. doi: 10.1097/MLR.0b013e3181e57918 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Long H, Brooks JM, Harvie M, Maxwell A, French DP. How do women experience a false-positive test result from breast screening? A systematic review and thematic synthesis of qualitative studies. Br J Cancer. Aug 2019;121(4):351–358. doi: 10.1038/s41416-019-0524-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Ho TH, Bissell MCS, Kerlikowske K, et al. Cumulative Probability of False-Positive Results After 10 Years of Screening With Digital Breast Tomosynthesis vs Digital Mammography. JAMA Netw Open. Mar 1 2022;5(3):e222440. doi: 10.1001/jamanetworkopen.2022.2440 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Mottram R, Knerr WL, Gallacher D, et al. Factors associated with attendance at screening for breast cancer: a systematic review and meta-analysis. BMJ Open. Nov 30 2021;11(11):e046660. doi: 10.1136/bmjopen-2020-046660 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Brewer NT, Salz T, Lillie SE. Systematic review: the long-term effects of false-positive mammograms. Ann Intern Med. Apr 3 2007;146(7):502–10. doi: 10.7326/0003-4819-146-7-200704030-00006 [DOI] [PubMed] [Google Scholar]
  • 10.Roman R, Sala M, De La Vega M, et al. Effect of false-positives and women’s characteristics on long-term adherence to breast cancer screening. Breast Cancer Res Treat. Nov 2011;130(2):543–52. doi: 10.1007/s10549-011-1581-4 [DOI] [PubMed] [Google Scholar]
  • 11.Klompenhouwer EG, Duijm LE, Voogd AC, et al. Re-attendance at biennial screening mammography following a repeated false positive recall. Breast Cancer Res Treat. Jun 2014;145(2):429–37. doi: 10.1007/s10549-014-2959-x [DOI] [PubMed] [Google Scholar]
  • 12.Setz-Pels W, Duijm LE, Coebergh JW, Rutten M, Nederend J, Voogd AC. Re-attendance after false-positive screening mammography: a population-based study in the Netherlands. Br J Cancer. Oct 15 2013;109(8):2044–50. doi: 10.1038/bjc.2013.573 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Alamo-Junquera D, Murta-Nascimento C, Macia F, et al. Effect of false-positive results on reattendance at breast cancer screening programmes in Spain. Eur J Public Health. Jun 2012;22(3):404–8. doi: 10.1093/eurpub/ckr057 [DOI] [PubMed] [Google Scholar]
  • 14.DeFrank JT, Rimer BK, Bowling JM, Earp JA, Breslau ES, Brewer NT. Influence of false-positive mammography results on subsequent screening: do physician recommendations buffer negative effects? J Med Screen. Mar 2012;19(1):35–41. doi: 10.1258/jms.2012.011123 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Fitzpatrick P, Fleming P, O’Neill S, Kiernan D, Mooney T. False-positive mammographic screening: factors influencing re-attendance over a decade of screening. J Med Screen. 2011;18(1):30–3. doi: 10.1258/jms.2010.010104 [DOI] [PubMed] [Google Scholar]
  • 16.Dabbous FM, Dolecek TA, Berbaum ML, et al. Impact of a False-Positive Screening Mammogram on Subsequent Screening Behavior and Stage at Breast Cancer Diagnosis. Cancer Epidemiol Biomarkers Prev. Mar 2017;26(3):397–403. doi: 10.1158/1055-9965.EPI-16-0524 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Henderson JT, Webber EM, Weyrich MS, Miller M, Melnikow J. Screening for Breast Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. Apr 30 2024;doi: 10.1001/jama.2023.25844 [DOI] [PubMed] [Google Scholar]
  • 18.U.S. Preventive Services Task Force. Evidence Gaps Research Taxonomy Table: Breast Cancer Screening. Updated 04/30/2024. Accessed 05/20/2024, https://www.uspreventiveservicestaskforce.org/uspstf/document/evidence-gaps-research-taxonomy-table/breast-cancer-screening
  • 19.von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. Apr 2008;61(4):344–9. doi:S0895-4356(07)00436-2 [pii] 10.1016/j.jclinepi.2007.11.008 [DOI] [PubMed] [Google Scholar]
  • 20.Siu AL, Force USPST. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. Feb 16 2016;164(4):279–96. doi: 10.7326/M15-2886 [DOI] [PubMed] [Google Scholar]
  • 21.Breast Cancer Surveillance Consortium. BCSC Standard Definitions v3.1. Breast Cancer Surveillance Consortium,. Updated 9/15/2023. Accessed 11/11/2023, https://www.bcsc-research.org/data/bcsc_standard_definitions [Google Scholar]
  • 22.USDA Economic Research Service U.S. Department of Agriculture. Rural-Urban Commuting Area Codes. Updated March 22, 2023. Accessed June 28, 2023, 2023. https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx
  • 23.American College of Radiology. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. American College of Radiology; 2013. [Google Scholar]
  • 24.U. S. Preventive Services Task Force, Nicholson WK, Silverstein M, et al. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Apr 30 2024;doi: 10.1001/jama.2024.5534 [DOI] [PubMed] [Google Scholar]
  • 25.Huang FL. Alternatives to logistic regression models in experimental studies. The Journal of Experimental Education. 2022/01/02 2019;90(1):213–228. doi: 10.1080/00220973.2019.1699769 [DOI] [Google Scholar]
  • 26.Miglioretti DL, Heagerty PJ. Marginal modeling of nonnested multilevel data using standard software. Am J Epidemiol. Feb 15 2007;165(4):453–63. doi: 10.1093/aje/kwk020 [DOI] [PubMed] [Google Scholar]
  • 27.Miglioretti DL, Heagerty PJ. Marginal modeling of multilevel binary data with time-varying covariates. Biostatistics. Jul 2004;5(3):381–98. doi: 10.1093/biostatistics/5.3.381 [DOI] [PubMed] [Google Scholar]
  • 28.Tice JA, Miglioretti DL, Li CS, Vachon CM, Gard CC, Kerlikowske K. Breast Density and Benign Breast Disease: Risk Assessment to Identify Women at High Risk of Breast Cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. Oct 1 2015;33(28):3137–43. doi: 10.1200/JCO.2015.60.8869 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Tice JA, O’Meara ES, Weaver DL, Vachon C, Ballard-Barbash R, Kerlikowske K. Benign breast disease, mammographic breast density, and the risk of breast cancer. J Natl Cancer Inst. Jul 17 2013;105(14):1043–9. doi: 10.1093/jnci/djt124 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Kerlikowske K, Chen S, Golmakani MK, et al. Cumulative Advanced Breast Cancer Risk Prediction Model Developed in a Screening Mammography Population. J Natl Cancer Inst. May 9 2022;114(5):676–685. doi: 10.1093/jnci/djac008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Henderson LM, Hubbard RA, Sprague BL, Zhu W, Kerlikowske K. Increased Risk of Developing Breast Cancer after a False-Positive Screening Mammogram. Cancer Epidemiol Biomarkers Prev. Dec 2015;24(12):1882–9. doi: 10.1158/1055-9965.EPI-15-0623 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Mao X, He W, Humphreys K, et al. Breast Cancer Incidence After a False-Positive Mammography Result. JAMA Oncol. Jan 1 2024;10(1):63–70. doi: 10.1001/jamaoncol.2023.4519 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Schwartz LM, Woloshin S, Fowler FJ Jr., Welch HG. Enthusiasm for cancer screening in the United States. JAMA. Jan 7 2004;291(1):71–8. doi: 10.1001/jama.291.1.71 [DOI] [PubMed] [Google Scholar]
  • 34.Ganott MA, Sumkin JH, King JL, et al. Screening mammography: Do women prefer a higher recall rate given the possibility of earlier detection of cancer? Radiology. 2006;238(3):793–800. [DOI] [PubMed] [Google Scholar]
  • 35.Jafri NF, Ayyala RS, Ozonoff A, Jordan-Gray J, Slanetz PJ. Screening mammography: does ethnicity influence patient preferences for higher recall rates given the potential for earlier detection of breast cancer? Radiology. Dec 2008;249(3):785–91. doi: 10.1148/radiol.2493072176 [DOI] [PubMed] [Google Scholar]
  • 36.Pisano ED, Earp J, Schell M, Vokaty K, Denham A. Screening behavior of women after a false-positive mammogram. Radiology. Jul 1998;208(1):245–9. doi: 10.1148/radiology.208.1.9646820 [DOI] [PubMed] [Google Scholar]
  • 37.Dontchos BN, Achibiri J, Mercaldo SF, et al. Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic. AJR Am J Roentgenol. Feb 2022;218(2):270–278. doi: 10.2214/AJR.21.26597 [DOI] [PubMed] [Google Scholar]
  • 38.Nelson HD, Pappas M, Cantor A, Griffin J, Daeges M, Humphrey L. Harms of Breast Cancer Screening: Systematic Review to Update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med. Feb 16 2016;164(4):256–67. doi: 10.7326/M15-0970 [DOI] [PubMed] [Google Scholar]
  • 39.Brocken P, Prins JB, Dekhuijzen PN, van der Heijden HF. The faster the better?-A systematic review on distress in the diagnostic phase of suspected cancer, and the influence of rapid diagnostic pathways. Psycho-oncology. Jan 2012;21(1):1–10. doi: 10.1002/pon.1929 [DOI] [PubMed] [Google Scholar]
  • 40.Harris RP, Sheridan SL, Lewis CL, et al. The harms of screening: a proposed taxonomy and application to lung cancer screening. JAMA internal medicine. Feb 1 2014;174(2):281–5. doi: 10.1001/jamainternmed.2013.12745 [DOI] [PubMed] [Google Scholar]
  • 41.Ho TH, Bissell MCS, Lee CI, et al. Prioritizing Screening Mammograms for Immediate Interpretation and Diagnostic Evaluation on the Basis of Risk for Recall. Journal of the American College of Radiology : JACR. Mar 2023;20(3):299–310. doi: 10.1016/j.jacr.2022.09.030 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.HealthCare.gov. Preventive health services. Accessed 01/07/2024, 2024. https://www.healthcare.gov/coverage/preventive-care-benefits/
  • 43.Lowry KP, Bell S, Fendrick AM, Carlos RC. Out-of-Pocket Costs of Diagnostic Breast Imaging Services After Screening Mammography Among Commercially Insured Women From 2010 to 2017. JAMA Netw Open. Aug 2 2021;4(8):e2121347. doi: 10.1001/jamanetworkopen.2021.21347 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Hughes DR, Espinoza W, Fein S, Rula EY, McGinty G. Patient Cost-Sharing and Utilization of Breast Cancer Diagnostic Imaging by Patients Undergoing Subsequent Testing After a Screening Mammogram. JAMA Netw Open. Mar 1 2023;6(3):e234893. doi: 10.1001/jamanetworkopen.2023.4893 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Brandzel SD, Bowles EJA, Wieneke A, et al. Cancer Screening Reminders: Addressing the Spectrum of Patient Preferences. Perm J. 2017;21:17–051. doi: 10.7812/TPP/17-051 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.As Reported by House Committee On: Health Care & Wellness. HOUSE BILL REPORT SSB 5396: An act relating to cost sharing for diagnostic and supplemental breast examinations. Accessed 01/16/2024, 2024. https://lawfilesext.leg.wa.gov/biennium/202324/Pdf/Bill%20Reports/House/5396-S%20HBR%20HCW%2023.pdf
  • 47.Goossens MC, De Brabander I, De Greve J, et al. Breast cancer risk is increased in the years following false-positive breast cancer screening. Eur J Cancer Prev. Sep 2017;26(5):396–403. doi: 10.1097/CEJ.0000000000000313 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.National Committee for Quality Assurance. Breast Cancer Screening. Accessed 01/02/2024, 2024. https://www.ncqa.org/hedis/measures/breast-cancer-screening/

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Supplementary Materials

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Supp Table 1
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Supp Figure 1
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