DOI:10.2214/AJR.04.1730
AJR 2007; 188:242-245
© American Roentgen Ray Society
Trends in Time to Completion of Mammographic Screening and Follow-Up Services
K. Robin Yabroff1,
Erin Ashbeck2 and
Robert Rosenberg2
1 Division of Cancer Control and Population Sciences, National Cancer Institute,
Executive Plaza North, Rm. 4005, 6130 Executive Blvd., MSC, Bethesda, MD
73445.
2 University of New Mexico Health Sciences Center, Albuquerque, NM
87131-5001.
Received November 9, 2004;
accepted after revision July 20, 2005.
Address correspondence to K. R. Yabroff.
Abstract
OBJECTIVE. The popular press has raised questions about mammographic
capacity in the United States, but mammographic utilization data have not been
used to inform these concerns. We used data for the period 1995-2002 from the
New Mexico Mammography Project to assess trends in time to completion of
mammographic screening and follow-up services.
CONCLUSION. The median time to return mammographic screening changed
little over time, but trends in the time required to complete recommended
follow-up services varied by type of service and urban or rural residence.
Further monitoring of time required to complete screening and follow-up
services in other regions can inform debates on mammographic capacity.
Keywords: breast cancer • breast neoplasms • mammography • mass screening • prevention • trend study
Introduction
The proportion of women in the United States who report recently having
undergone mammography has increased dramatically, from 28.8% in 1987
[1] to 70.1% in 2000
[2]. Stories in the popular
press [3,
4] have questioned the capacity
of mammographic facilities to provide breast cancer screening services to
these women. A U.S. General Accounting Office report on mammographic capacity
concluded that in general, adequate mammographic services for screening and
follow-up were available between 1998 and 2001
[5]. In some geographic areas,
however, capacity declined, and in combination with increasing demand led to
long waiting times for appointments
[5]. Concerns about
mammographic capacity were also mentioned in an Institute of Medicine report
[6] on breast cancer detection
and diagnosis. To our knowledge, however, mammographic utilization data have
not been used to inform concerns about scheduling delays and mammographic
capacity.
Materials and Methods
We used 1995-2002 data from the New Mexico Mammography Project, a
population-based mammography registry with linkages to the New Mexico
Surveillance Epidemiology and End Results tumor registry and pathology
laboratory data [7], to assess
annual trends in time required to complete return screening and recommended
follow-up services. The New Mexico Mammography Project is a member of the
Breast Cancer Surveillance Consortium, a larger effort to assess the
performance of mammographic screening in clinical practice
[8]. The University of New
Mexico institutional review board approved the New Mexico Mammography Project,
and deidentified data were used for this study.
An index screening examination was defined as bilateral mammography with a
screening indication in patients without a prior mammogram in the past 9
months or a report of symptoms. The population was women 40-79 years old
living in New Mexico. Women with a personal history of breast cancer or breast
implants were excluded. U.S. Department of Agriculture urban-rural continuum
codes were used to assign urban or rural status on the basis of county of
residence [9]. From the
selected index screening examinations, we identified three samples for
assessment of time from the index screening examination to return screening
examination, completion of recommended additional imaging (i.e., mammographic
views, sonography), and completion of recommended biopsy or surgery.
Recommendations for fine-needle aspiration were not included, because many
fluid samples are not submitted for laboratory evaluation.
Because some women receive screening or follow-up services outside of New
Mexico Mammography Project facilities, samples were limited to index
mammograms with a record of return mammogram within 2.5 years of index
mammogram, additional imaging within 6 months of index mammogram, and
pathology report within 6 months of index mammogram (or a subsequent service
within 90 days with a biopsy recommendation). Estimates of time to completion
of recommended services were stratified by urban-rural status and graphed with
Kaplan-Meier plots.
Results
Between 1995 and 2001, 479,499 index mammograms met the inclusion criteria.
Thirty-two percent of the women were 40-49 years old at the examination; 32%
were 50-59 years old; 22% were 60-69 years old; and 14% were 70-79 years old.
The proportions of women 65 years and older were similar in urban and rural
areas. Ninety percent of the women reported white race; 6%, American Indian;
and 4%, other or unknown race. Approximately 30% of the patients reported
Hispanic ethnicity. Seventy-six percent of the women lived in an urban county.
The number of mammograms and age, race, and ethnicity distributions in our
data were consistent over the study years, but the proportion of women living
in rural counties increased.
Between 1995 and 2000, 238,941 index mammograms had a recommendation for
normal follow-up and a recorded return screening mammogram within 2.5 years.
Between 1995 and 2001, 39,538 index mammograms with a recommendation for
additional imaging and 4,094 index mammograms with a recommendation for biopsy
or surgery had records of these procedures within 6 months.
Median time to recorded return mammogram was similar across all years and
for urban and rural areas, approximately 416 days
(Fig. 1). Median time to
recorded additional imaging increased in urban areas from 7 days in 1995 to 14
days in 2001 (Table 1). This
figure remained stable in rural areas with a median of 14 days (Figs.
2A and
2B). Median time to recorded
biopsy or surgery decreased only in urban areas, from 22 days in 1995 to 15
days in 2001 (Figs. 3A and
3B).
View this table:
[in this window]
[in a new window]
|
TABLE 1: Time to Completion of Recommended Follow-Up Services After Abnormal
Mammographic Findings in Women Living in Urban and Rural Areas,
1995–2001
|
|
Discussion
In this study, we used population-based data for 1995-2002 from the New
Mexico Mammography Project to assess annual trends in time required to
complete return screening and follow-up services. The median time to return
mammographic screening changed little over time, but trends in time required
to complete follow-up services varied by type of service and urban or rural
residence. Time to completion of recommended biopsy or surgery, the most
serious of abnormal findings, declined in urban areas. Changes in practice
patterns, decreasing use of excisional biopsy by surgeons, and increasing use
of on-site core biopsy by radiologists have been reported
[10-12].
Such changes in practice and referral patterns may help explain the observed
decline in time required for completion of biopsy or surgery in urban
areas.
The median time to completion of additional imaging increased in urban
areas over the period 1995 and 2001 but remained stable in rural areas.
Although the clinical effect of these changes in time to completion of
recommended follow-up services is unclear, further monitoring of trends will
be an important area for additional research. Evaluation of such trends may
also be useful for assessing the effect of policy changes related to
mammographic screening. For example, starting in January 2002, a change in
Medicare reimbursement allowed claims for screening mammography and diagnostic
mammography on the same day for the same patient. Medicare previously
reimbursed claims only for screening and diagnostic mammograms performed on
different days, or same-day screening and diagnostic mammograms were converted
to diagnostic mammography for payment purposes
[13]. Any changes in practice
associated with this policy could have occurred only in facilities that use
real-time interpretation of mammograms while the woman is present in the
facility, rather than batch interpretation conducted at a later time.
Factors at multiple levels may influence the delivery and timing of
screening and follow-up services, including facility characteristics, such as
the number and type of machines
[5], supply of radiologists and
mammographic technologists [5],
and characteristics of women receiving services
[5,
14-19].
Area of residence
[16-19];
social, economic, and cultural characteristics
[14,
15,
18,
19]; and insurance status
[5,
19] have been reported to be
associated with timing of recommended screening and follow-up services.
Changes in mammographic practice that vary by facility, such as batch
reviewing, double reviewing, computer-assisted diagnosis
[20], clustering of diagnostic
studies, and diffusion of new technologies
[20,
21] may also affect trends in
time required for screening and follow-up services. Further development of
these data and exploration of the interrelation among these factors may inform
understanding of trends in delivery and timing of screening and follow-up
services.
Strengths of this study include the comprehensive data on mammography and
related services and the large sample sizes for annual trend comparisons.
Exclusion of index mammograms without evidence of completion of recommended
return screening or follow-up services may limit ability to generalize the
findings, because some of these women may have completed services at
facilities outside of the New Mexico Mammography Project. We did not evaluate
completeness of repeated screening or follow-up, although this factor can be
explored in a setting with complete coverage of mammographic facilities. In
addition, it may not be possible to generalize findings from New Mexico to the
rest of the United States. Replication of this study within the larger Breast
Cancer Surveillance Consortium, which represents six other geographic regions
[8], may provide additional
insight into trends in time required for completion of mammography and
follow-up services. Further monitoring of trends in screening and follow-up
services and evaluation of the influence of facility, provider, and
woman-level factors can inform future debates on mammographic capacity.
Acknowledgments
We acknowledge Martin Brown for thoughtful comments on an earlier version
of this manuscript.
References
- Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R.
Progress in cancer screening over a decade: results of cancer screening from
the 1987, 1992, and 1998 National Health Interview Surveys. J Natl
Cancer Inst 2001;93:1704
-1713[Abstract/Free Full Text]
- Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer
screening practices in the United States: results from the 2000 National
Health Interview Survey. Cancer2003; 97:1528
-1540[CrossRef][Medline]
- Lombard KS. Waiting for mammograms. The New York
Times, March 10, 2002. Available at
www.nytimes.com.
Accessed October 25, 2006
- Gorman C. Need a mammogram? It could take a while.
Time, March 12, 2001;78
-81
- Mammography capacity generally exists to deliver
services. Washington, DC: U.S. General Accounting Office,2002
, Report GAO-02-532
- Joy JE, Penhoet EE, Petitti DB. Saving women's lives:
strategies for improving breast cancer detection and diagnosis.
Washington, DC: National Academies Press, 2004
- Rosenberg RD, Land JF, Hunt WC, et al. The New Mexico Mammography
Project: screening mammography performance in Albuquerque, New Mexico, 1991 to
1993. Cancer1996; 78:1731
-1739[CrossRef][Medline]
- Ballard-Barbash R, Taplin SH, Yankaskas BC, et al. Breast Cancer
Surveillance Consortium: a National Mammography Screening and Outcomes
Database. AJR1997; 169:1001
-1008[Free Full Text]
- Butler MA, Beale CL. Rural-urban continuum codes for metro
and nonmetro counties. Beltsville, MD: Agriculture and Rural Economy
Division, Economic Research Service, U.S. Department of Agriculture,1994
, staff report 9425
- Crowe JP Jr, Rim A, Patrick R, et al. A prospective review of the
decline of excisional breast biopsy. Am J Surg2002; 184:353
-355[CrossRef][Medline]
- Rubin E, Mennemeyer ST, Desmond RA, et al. Reducing the cost of
diagnosis of breast carcinoma: impact of ultrasound and imaging-guided
biopsies on clinical breast practice. Cancer2001; 91:324
-332[CrossRef][Medline]
- March DE, Raslavicus A, Coughli BF, Klein SV, Makari-Judson G. Use
of breast core biopsy in the United States: results of a national survey.
AJR 1997;169:697
-701[Abstract/Free Full Text]
- Centers for Medicare and Medicaid Services. Medicare
claims processing manual. Available at
www.cms.hhs.gov/manuals/downloads/clm104c18pdf.
Accessed October 25, 2006
- Chang SW, Kerlikowske K, Napoles-Springer A, Posner SF, Sickles EA,
Perez-Stable EJ. Racial differences in timeliness of follow-up after abnormal
screening mammography. Cancer1996; 78:1395
-1402[CrossRef][Medline]
- Strzelczyk JJ, Dignan MB. Disparities in adherence to recommended
follow-up on screening mammography: interaction of sociodemographic factors.
Ethn Dis 2002;12:77
-86[Medline]
- Coughlin SS, Thompson TD, Hall HI, Logan P, Uhler RJ. Breast and
cervical carcinoma screening practices among women in rural and nonrural areas
of the United States, 1989-1999. Cancer2002; 94:2801
-2812[CrossRef][Medline]
- Schootman M, Myers-Geadelmann J, Fuortes L. Factors associated with
adequacy of diagnostic workup after abnormal breast cancer screening results.
J Am Board Fam Pract2000; 13:94
-100
- Kerner JF, Yedidia M, Padgett D, et al. Realizing the promise of
breast cancer screening: clinical follow-up after abnormal screening in black
women. Prev Med2003; 37:92
-101[CrossRef][Medline]
- Peek ME, Han JH. Disparities in screening mammography: current
status, interventions, and implications. J Gen Intern
Med 2004;19:184
-194[CrossRef][Medline]
- Nass SJ, Henderson C, Lashof JC. Mammography and beyond:
developing technologies for the early detection of breast cancer.
Washington, DC: National Academy Press, 2001
- Esserman LJ. New approaches to the imaging, diagnosis, and biopsy
of breast lesions. Cancer J2002; 8:S1
-S14
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
