Effect of Screening Mammography on Other Preventive Services in Older Women

See also the article by Kang et al in this issue.

Introduction

The potential for the use and results of screening mammography to affect women’s adherence to other preventive guidelines has implications for population health. For adult women, preventive services, including screening mammography, are commonly recommended according to clinical practice guidelines. The American College of Radiology and the Society of Breast Imaging support annual screening mammography starting at age 40 years (1). The American Cancer Society recommends that women age 40–44 years have the choice to start annual screening mammography if they wish to do so (2). The American Cancer Society recommends that women ages 45–54 years should get yearly mammograms, and women ages 55 years and older can continue with annual mammography or switch to mammography every 2 years (2). The U.S. Preventive Services Task Force recommends biennial screening mammography for women ages 50–74 years (3). As women decide whether or not to follow preventive guidelines, the decision of whether or not to comply may be influenced by population-level risks presented to them or by nonprobabilistic factors, such as their personal experience with a test or a disease, or the experience of a friend or a family member. In addition, little is known regarding the effect of false-positive findings at mammography on the use of other nonbreast preventive services (4).

In this issue of Radiology, Kang et al (5) performed a retrospective analysis and showed that female U.S. Medicare beneficiaries who underwent screening mammography had increased use of cervical cancer and osteoporosis screening tests, as well as the influenza vaccine. The findings suggest that women who are Medicare beneficiaries who undergo screening mammography may be more likely to follow nonbreast cancer–related preventive guidelines. These findings may be relevant in daily clinical practice and in policy decisions regarding coverage for bundled preventive tests, including screening mammography (5).

In their study (5), Kang et al demonstrated that use of screening mammography was associated with the use of other screening tests and other preventive measures. On a practical level, test ordering and scheduling should take advantage of these associations. For example, screening mammography and other tests could be scheduled on the same day or within a short time period (ie, within 2 weeks). On a policy level, interventions from the field of behavioral economics should be considered. For example, undergoing screening mammography, cervical cancer screening, and osteoporosis screening within a 2-week period could result in a discounted financial charge to the patient or a merit for the ordering primary care physician.

This study (5) also helps us to examine the consequences of false-positive findings at mammography. The authors defined false-positive results as results assessed as positive at screening studies with no breast cancer diagnosis within the year after the screening examination. Previous studies (4,6) of false-positive mammography identified increased costs and psychosocial harms, including anxiety and distress, which may persist for months following the false-positive findings. In some patients, false-positive findings at mammography may lead to the initiation of antidepressants and anxiolytics (7). False-positive results at mammography, which are relatively common (cumulative probability, 42%–61% over a 10-year screening period) are also associated with an increased perception of individual risk, despite no actual change in real risk (6). It is important to know that in this study of 185 625 women who underwent mammographic screening, there was no association with decreased use of preventive services in the 2 years following false-positive findings at screening mammography (5).

These findings are concordant with a study by Tosteson et al (8), who analyzed women participating in the Digital Mammographic Imaging Screening Trial in a quality-of-life substudy and found that women with false-positive findings at mammography characterized themselves as more likely to undergo future breast cancer screening than women who had a negative result at mammography. Tosteson et al noted that a woman’s intention to undergo breast cancer screening was increased twofold among women who had false-positive results at mammography (8). The findings noted in Kang et al (5) are also in agreement with an earlier study by Pisano et al (9), who studied 43 patients with abnormal mammography followed within 6 months by benign excisional biopsies, and 136 control participants. Pisano et al noted that the study patients were more likely than the control patients to undergo annual screening mammography in the future (9). Pisano et al noted that false-positive findings at mammography may serve as a so-called teachable moment because they theorized that when a woman is in a threatening situation or a situation characterized by ambiguity, she may be more accepting of health education messaging and more willing to act on recommendations and pursue screening (9).

The authors analyzed the behavior of women who were older than 65 years and were beneficiaries of Medicare (5). It is likely that Medicare beneficiaries were chosen for this analysis because Medicare data are easily identifiable and attainable and commonly used for studies such as this one. Future studies should be undertaken to analyze the use of screening examinations by younger women and non-Medicare beneficiaries. We need to know if screening behavior is influenced by age or by woman. Furthermore, in this study, 88.3% of the women were white and 78.5% lived in urban areas (5). Future studies should examine the screening test usage patterns of nonwhite and rural women. We need to determine if similar results can be obtained in other populations.

This study (5) is a good addition to the literature regarding the associations between the use of screening mammography and the use of other screening tests. Women who undergo screening mammography tend to practice other preventive health behaviors. However, women may participate in some screening and preventive activities and not participate in others. More studies are needed to determine what interventions are effective in increasing compliance in screening and preventive behaviors across a wide spectrum, including screening for specific cancers such as breast and cervical cancer, osteoporosis screening, and use of vaccinations. In addition, future studies should analyze the associations between the use of other screening studies, such as blood pressure screening and colorectal cancer screening, and the use of other preventive services, such as eye examinations. Future studies are needed to develop optimal screening test ordering and scheduling routines and policies for a broader age group in various geographic areas with different women's profiles. We need to examine other established programs, such as the National Breast and Cervical Cancer Early Detection Program, a nationally organized cancer screening program for underserved U.S. women (10), to develop optimal screening and preventive strategies and programs for a wide range of women in different practice settings, including public education and outreach, quality assurance, quality improvement, case management, and navigation, and data management (10).