Breast cancer screening: can we talk?

Breast cancer affects over 175,000 women in the United States each year,1 but its impact is felt by far more individuals than just those who have the diagnosis. With increased public awareness of the disease have come increased levels of anxiety. Women perceive breast cancer as their greatest health risk, even though they are far more likely to die from coronary heart disease. This erroneous perception is probably magnified by many women's personal experience with a friend or relative struck with the disease in the prime of her life. The fear of breast cancer often factors into a woman's decision on whether to pursue hormone replacement therapy. Yet, despite these fears, not every woman is being screened appropriately, and a host of other issues, including cost, inconvenience, and discomfort from the procedure, are often cited by patients as the reason. Mammography remains the gold standard screening technique and offers an effective means to detect breast cancer early. It is noninvasive, relatively inexpensive, and has reasonable sensitivity (72–88%) that increases with age.2,3 Its primary advantage is the ability to detect tumors less than 1 cm in size and before clinically palpable, in the hopes of intervening early to improve survival. In fact, a meta-analysis of randomized, controlled trials of screening mammography found a relative risk for breast cancer mortality of 0.74 (95% confidence interval, 0.66 to 0.83) in women age 50 and older.4 Data collected by the Behavioral Risk Factor Surveillance System (BRFSS) from 38 state health departments showed that the proportion of women over age 40 years who reported ever having undergone mammography increased steadily from 64% in 1989 to 85% in 1997.5 Encouraging, right? Well, yes, but that same BRFSS data set demonstrated that there are also discouraging findings. The proportion of women who had a mammogram in the prior two years did not increase to the same degree as the proportion ever having a mammogram. This suggests that women are not returning for their periodic follow-up mammograms. There is also the frequently reported observation that screening is less likely to occur in women with low income, low educational level, or no health insurance.5 And finally, women have to contend with a 10% false-positive rate for mammography.6 Indeed, for all of the benefits of screening mammography, it remains an imperfect tool. Three articles in this issue of the Journal tackle these difficult aspects of breast cancer screening. Dolan and colleagues address the anxiety women experience while awaiting results after being screened.7 A telephone survey was used to assess patients' satisfaction with the reporting of mammogram results as well as their understanding of the results. The investigators contacted 298 patients who had undergone mammography at an academic medical center and discovered women with screening exams (as opposed to diagnostic exams with immediate feedback) were more likely to be dissatisfied. Waiting for results for greater than 2 weeks, difficulty in contacting a medical person to answer questions, fair to poor ratings of how well results were communicated, and having a considerable amount of anxiety were also associated with dissatisfaction with screening exams. In the past, the Journal has published articles illuminating the pivotal role of communication between physician and patient,8,9 and it again is borne out by this study. Anxiety of a different sort — namely that associated with a false-positive screening mammogram — is examined in an article by Barton et al.10 It has been previously shown that women with high-suspicion mammograms but no subsequent malignancy still experience significant anxiety that can affect both mood and daily functioning.11 Barton et al. take these findings one step further and assess the impact of false-positive mammogram results on subsequent ambulatory visit rate. They conducted a 12-month retrospective cohort study of 496 women with false-positive screening mammograms and 296 women with normal mammograms. The results indicated that women with false-positive mammograms had higher rates of breast-related visits (incidence ratio 1.69) and even non-breast-related visits (incidence ratio 1.14). Chart review revealed a documented breast concern during those 12 months in 10% of women with false-positive studies vs. 0.2% of women with normal studies. There was a dose-response effect in that patients with greater intensity of follow-up recommendations had higher documented concern. Clearly, breast cancer screening can be associated not only with greater anxiety, but also with increased health care resource utilization and the economic concerns that accompany it. While not addressed by the authors, one must ask whether an adequate level of reassurance and communication was provided to these patients in the face of a distressing false-positive result — and whether the increased economic burden of subsequent ambulatory visits could have been minimized. Another article by Barton et al. in this issue of the Journal examined the rates of mammography utilization in 1667 women patients enrolled in a single health maintenance organization.12 Despite the fact that mammography was covered from a payment perspective, socioeconomic status was still found to be a significant correlate of utilization. Each increment of $10,000 in income increased the mammography rate by 2.5 percentage points. By using a fairly homogeneous population with respect to mammogram coverage, the authors tried to tease out if cost is truly a barrier to screening. The results suggest not. We can only hypothesize about what obstacles to screening are truly meaningful for this population, but we can start to address the problem by making sure the lines of communication between patient and physician are open and effective. A comfortable and honest rapport is the first step toward education with results. All these studies shed light on the breast cancer screening process. Moreover, each article highlights, either directly or indirectly, the importance of communication between patient and physician. Whether we are communicating mammography results in a timely fashion, communicating reassurance to an anxious patient after a false-positive result, or communicating the importance of breast cancer screening, we must find the time to deliver our message, and in turn take the time to listen. Breast cancer screening will only get more complicated in the future, as more questions arise: specifically, what should be done with women at either end of the age spectrum — between 40–49 years and over the age of 75? How should we handle high-risk patients? Will other modalities such as magnetic resonance imaging or ductal washing be more effective or function simply as adjuncts to mammography? It is no longer enough just to order a screening mammogram on all appropriate patients. We as internists need to sit our patients down before and after the procedure and ask, “Can we talk?”