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Cumulative Probability of False-Positive Recall or Biopsy Recommendation After 10 Years of Screening Mammography: A Cohort Study

Rebecca A. Hubbard, PhD; Karla Kerlikowske, MD; Chris I. Flowers, MD; Bonnie C. Yankaskas, PhD; Weiwei Zhu, MS; and Diana L. Miglioretti, PhD
[+] Article and Author Information

From Group Health Cooperative and School of Public Health of the University of Washington, Seattle, Washington; University of California, San Francisco, San Francisco, California; Moffitt Cancer Center and Research Institute, Tampa, Florida; and University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.


Acknowledgment: The authors thank the participating women, mammography facilities, and radiologists for the data they have provided for this study. A list of BCSC investigators and procedures for requesting BCSC data for research purposes is available at http://breastscreening.cancer.gov.

Grant Support: By the National Cancer Institute–funded Breast Cancer Surveillance Consortium cooperative agreement (grants U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, and U01CA70040) and the National Cancer Institute–funded grants R03CA150007 and RC2CA148577. The collection of cancer data used in this study was supported in part by several state public health departments and cancer registries throughout the United States. For a full description of these sources, please see http://breastscreening.cancer.gov/work/acknowledgement.html.

Potential Conflicts of Interest: Dr. Hubbard: Grant (money to institution): NCI; Grants/grants pending (money to institution): NCI. Dr. Kerlikowske: Grant (money to institution): NCI. Dr. Flowers: Payment for development of educational presentations: Oakstone Publishing. Dr. Yankaskas: Grant (money to institution): NCI/NIH; Support for travel to meetings for study or other purposes (money to institution): NCI/NIH. Dr. Zhu: Grant: NCI. Dr. Miglioretti: Grant (money to institution): NCI; Grants/grants pending (money to institution): NCI. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2026.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Hubbard (hubbard.r@ghc.org). Data set: Available following approval by the BCSC Steering Committee (http://breastscreening.cancer.gov).

Requests for Single Reprints: Rebecca A. Hubbard, PhD, Group Health Research Institute, Suite 1600, 1730 Minor Avenue, Seattle, WA 98101-1448; e-mail, hubbard.r@ghc.org.

Current Author Addresses: Drs. Hubbard and Miglioretti and Ms. Zhu: Group Health Research Institute, Suite 1600, 1730 Minor Avenue, Seattle, WA 98101-1448.

Dr. Kerlikowske: University of California, San Francisco, 4150 Clement Street, San Francisco, CA 94121.

Dr. Flowers: H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612.

Dr. Yankaskas: Department of Radiology, CB #7515, MRI, University of North Carolina, 106 Mason Farm Road, Chapel Hill, NC 27599-7515.

Author Contributions: Conception and design: R.A. Hubbard, K. Kerlikowske, C.I. Flowers, D.L. Miglioretti.

Analysis and interpretation of the data: R.A. Hubbard, K. Kerlikowske, B.C. Yankaskas, W. Zhu, D.L. Miglioretti.

Drafting of the article: R.A. Hubbard, K. Kerlikowske, C.I. Flowers, B.C. Yankaskas.

Critical revision of the article for important intellectual content: R.A. Hubbard, K. Kerlikowske, C.I. Flowers, W. Zhu, D.L. Miglioretti.

Final approval of the article: R.A. Hubbard, K. Kerlikowske, C.I. Flowers, B.C. Yankaskas, W. Zhu, D.L. Miglioretti.

Provision of study materials or patients: K. Kerlikowske, B.C. Yankaskas.

Statistical expertise: W. Zhu, D.L. Miglioretti.

Obtaining of funding: R.A. Hubbard, K. Kerlikowske, B.C. Yankaskas, D.L. Miglioretti.

Administrative, technical, or logistic support: K. Kerlikowske.

Collection and assembly of data: R.A. Hubbard, K. Kerlikowske, W. Zhu, D.L. Miglioretti.


Ann Intern Med. 2011;155(8):481-492. doi:10.7326/0003-4819-155-8-201110180-00004
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Background: False-positive mammography results are common. Biennial screening may decrease the cumulative probability of false-positive results across many years of repeated screening but could also delay cancer diagnosis.

Objective: To compare the cumulative probability of false-positive results and the stage distribution of incident breast cancer after 10 years of annual or biennial screening mammography.

Design: Prospective cohort study.

Setting: 7 mammography registries in the National Cancer Institute–funded Breast Cancer Surveillance Consortium.

Participants: 169 456 women who underwent first screening mammography at age 40 to 59 years between 1994 and 2006 and 4492 women with incident invasive breast cancer diagnosed between 1996 and 2006.

Measurements: False-positive recalls and biopsy recommendations stage distribution of incident breast cancer.

Results: False-positive recall probability was 16.3% at first and 9.6% at subsequent mammography. Probability of false-positive biopsy recommendation was 2.5% at first and 1.0% at subsequent examinations. Availability of comparison mammograms halved the odds of a false-positive recall (adjusted odds ratio, 0.50 [95% CI, 0.45 to 0.56]). When screening began at age 40 years, the cumulative probability of a woman receiving at least 1 false-positive recall after 10 years was 61.3% (CI, 59.4% to 63.1%) with annual and 41.6% (CI, 40.6% to 42.5%) with biennial screening. Cumulative probability of false-positive biopsy recommendation was 7.0% (CI, 6.1% to 7.8%) with annual and 4.8% (CI, 4.4% to 5.2%) with biennial screening. Estimates were similar when screening began at age 50 years. A non–statistically significant increase in the proportion of late-stage cancers was observed with biennial compared with annual screening (absolute increases, 3.3 percentage points [CI, −1.1 to 7.8 percentage points] for women age 40 to 49 years and 2.3 percentage points [CI, −1.0 to 5.7 percentage points] for women age 50 to 59 years) among women with incident breast cancer.

Limitations: Few women underwent screening over the entire 10-year period. Radiologist characteristics influence recall rates and were unavailable. Most mammograms were film rather than digital. Incident cancer was analyzed in a small sample of women who developed cancer.

Conclusion: After 10 years of annual screening, more than half of women will receive at least 1 false-positive recall, and 7% to 9% will receive a false-positive biopsy recommendation. Biennial screening appears to reduce the cumulative probability of false-positive results after 10 years but may be associated with a small absolute increase in the probability of late-stage cancer diagnosis.

Primary Funding Source: National Cancer Institute.

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Summary for Patients

The Benefits and Harms of More and Less Frequent Screening Mammography

The full report is titled “Cumulative Probability of False-Positive Recall or Biopsy Recommendation After 10 Years of Screening Mammography. A Cohort Study.” It is in the 18 October 2011 issue of Annals of Internal Medicine (volume 155, pages 481-492). The authors are R.A. Hubbard, K. Kerlikowske, C.I. Flowers, B.C. Yankaskas, W. Zhu, and D.L. Miglioretti.

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