Studies of fear in the context of screening mammography behavior have reported conflicting results. Some studies have shown that fear of breast cancer could be a facilitator of breast cancer screening, whereas others disagree, showing fear to be a barrier. Fear of cancer, particularly among African American women, has been linked to poorer screening [13, 14]. The fear of receiving a breast cancer diagnosis is also shared among Hispanic women and has been cited as one of the reasons for low rates of screening in this group of women [15–17].

Other studies, however, have suggested that patients with a greater degree of fear are associated with higher likelihood of undergoing screening [17]. One Swedish study of 434 nonattenders and 515 attenders showed that women who worried most about breast cancer were more likely to get screened [18]. Similar results were found in another study of 1384 American-born European and African American women, along with English-speaking Caribbean, Haitian, Dominican, and eastern European women in New York City, which showed that worry about cancer was positively associated with mammography [17].

Addressing the patients' fears would greatly improve customer satisfaction and the patient experience, ultimately leading to increased participation in breast cancer screening. A lack of available information for patients has been cited as one of the reasons for the perceived fear of screening mammography [19]. Improved patient education on the benefits and adverse effects of breast cancer screening before undergoing a mammogram study is of paramount importance. This can be accomplished by offering patient educators such as a nurse or physician assistant working for the mammography facility who can counsel the patients on the risks, benefits, uncertainties, and alternatives associated with a screening mammogram when she schedules her appointment. The U.S. Preventive Services Task Force encourages informed and joint decisions when deciding on a preventive service [20]. Because some patients may benefit from a service and others may not, shared decision making offers a way of individualizing recommendations according to patients' special needs and preferences. Alternatively, if a practice does not have the resources to offer a patient educator, information can be mailed either electronically or conventionally to the patient before her appointment. In addition, at the time of the study, enhancing patient education on what to expect when obtaining the various breast imaging studies has been shown to be effective in reducing patient anxiety and encouraging participation in screening. This could be done by providing written information, such as pamphlets, made available to patients while they wait for their study, as well as through direct communication with the patients at the time of the visit [21].

For some women, breast compression necessary for obtaining good mammographic images and reducing radiation dose is a source of pain and has been cited as a barrier to screening mammography. Reliably measuring the degree of pain associated with mammography is difficult. Some studies report that only 15% or 28% of women experience moderate or severe pain when undergoing mammography [22, 23]. In the study by Sharp and colleagues [23], 200 women were asked to rate their pain on a pain scale from 0 to 10, where 0 is “no pain at all” and 10 is the “worst pain you have ever felt”; 72% of the women rated the experience as less than or at 4. Because this rating was below the midpoint of 5, it was considered to be about average. Although there have been reports that a larger percentage of women (77%) have experienced moderate or severe pain, these reported higher levels of pain are short lived, lasting 10 minutes or less with only a small percentage of women (12%) having experienced the type of pain that could deter patients from future screening.

Reducing pain by decreasing the amount of compression used for imaging has been studied. In a double-blinded intraindividual study comparing conventional 14 daN force-standardized compression protocol with a personalized 10 kPa pressure-standardized protocol found that pain was significantly reduced without increasing average glandular dose or retakes [24]. In another study, pain and anxiety were reduced in women who received face-to-face information about the screening program before the mammography, as well as in those women who were provided support during the test [25].

Introducing counseling services during the patient visit may benefit women who express concerns about potential pain [23]. Providing the patients with specific information on the degree of pain they might experience would inform patients as to what to expect and also remove the element of surprise. In addition, it would be informative to describe to patients the expected level of pain by using a pain scale. Explaining that the amount of pain experienced would be around a “4” in a 0–10 scale, or describing it as pain analogous to the discomfort experienced from a mild headache or tight shoes, would significantly reduce patient anxiety before the study [23].

In screening mammography, a false-positive screening mammogram is defined as no tissue diagnosis of cancer within 1 year of having a screening mammogram recalled for additional workup (BI-RADS category 0, 4, or 5) [26]. In the United States, the cumulative probability of a woman receiving at least one false-positive recall after 10 years of screening ranges between 43% and 61% [27–29]. Asymptomatic women presenting for breast cancer screening expect confirmation of good health and are often surprised when a recall letter is received.

The psychologic effect of false-positive findings has been studied in women undergoing screening mammography. A meta-analysis that looked at the psychologic effect of having false-positive mammograms found that women who were recalled for additional workup after screening were more likely to be anxious and distressed about breast cancer [30]. Whether the psychologic effects of false-positive findings are short term or long term is uncertain. One study showed that anxiety experienced by women undergoing screening mammography was short term and of limited harm. However, other studies have shown that false-positive screening mammography can cause long-term psychosocial harm [31, 32]. In one of these studies, 454 women with abnormal findings in screening mammography were followed with a validated questionnaire encompassing 12 psychosocial outcomes, at baseline and at 1, 6, 18, and 36 months. The women experienced psychosocial consequences that ranged between those experienced by women receiving normal results and those with a diagnosis of breast cancer. These effects were present in some cases 3 years after the false-positive finding [32].

Using the customer intimacy model, it is clear that making changes to decrease false-positive findings in screening mammography would improve patient satisfaction. Considerable variation exists in recall rates, ranging from 1% to 15% among different radiologists and practices [33]. A study looking at the association between sensitivity and positive predictive values of screening mammography found that, to achieve the best trade-off between these two variables, the recall rates should be in the order of about 5% [34]. To decrease recall rates and urge breast imagers to reach this target rate, a combination of performance measures can be used to identify physicians with suboptimal performance in the interpretation of screening mammograms [35]. A radiologist who is not able to meet these performance measures could be asked to consider additional focused continuing medical education to improve performance [35].

In most centers throughout the United States, breast cancer screening and workup often follow the traditional breast imaging flow model. The delivery of care in this model is often fragmented with screening, diagnostic, ultrasound, and biopsy components performed at separate times and, in some centers, at different locations [36]. In parts of the United States with limited access, it is not rare for patients to be forced to wait several months to get a screening mammogram [37]. Once a patient has obtained her mammogram, she may be asked to wait additional days or weeks to receive the screening results. The wait time is further prolonged if an abnormality is identified at screening. The patient is then recalled for diagnostic imaging and spends more time waiting for the additional workup, all the while wondering anxiously whether she has cancer. The time from initial screening to diagnosis can extend to weeks or months. When women were questioned about what bothered them most regarding the entire process of obtaining a mammogram, the majority responded that waiting for results was most stressful—more stressful than actually having the mammogram done [23].

Patient satisfaction can be greatly improved by using the online breast imaging flow model in place of the traditional flow model. In this patient-centered online model, all reading is done in real time, and results are given to the patient before she leaves the facility [36]. The potential advantages of immediate interpretation of screening mammograms include a decrease in wait times for examination results and a reduction in second visits if an abnormality is detected. Surveys of patient preferences have shown that patients prefer to have radiologists provide them with the imaging findings immediately after the examination [37–40]. In addition, patients are more likely to comply with the screening mammogram recommendation if they are able to get a same-day appointment for the examination. The effect of same-day screening mammography has been found to increase women's adherence rates for physician-recommended screening mammography [41]. The rate of failed appointments can vary significantly depending on the waiting interval, with a peak failure rate of 27% for appointments scheduled 14–27 days in advance [42]. On the other hand, a potential disadvantage does exist for the online breast imaging flow model. Studies have shown that immediate real-time readings, compared with batch reading of screening mammograms, can increase recall rates [43–45], with increased base-case cost attributed to inefficiency and increased likelihood of extra mammographic views [45]. Although offering same-day screening appointments, immediate interpretation, and workup may not be operationally efficient, it can build patient loyalty, improve patient satisfaction, and decrease patient stress associated with breast cancer screening and workup. Immediate reading can also result in fewer return visits for the patient and has the potential to decrease time to breast cancer diagnosis.

In situations where a facility does not have the resources to offer real-time readings, a potential strategy to increase patient satisfaction is to improve communication of screening results and to build flexibility in scheduling for diagnostic workups and biopsies. Improved communication can be achieved by decreasing the turnaround time. Flexibility in scheduling for rapid workup of patients recalled from a screening mammogram can help decrease wait times.

One of the key features of the customer intimacy model is tailoring services to meet the needs of the individual. With breast cancer screening, care should be individualized according to various patient factors, such as breast cancer risk and breast density. Stratifying patients according to risk levels is helpful in providing the most appropriate screening recommendations and counseling. If feasible, onsite genetic counseling can be offered to those who are not sure of their risks. For those women who are determined to be of high risk (i.e., women with a BRCA gene mutation and their untested first-degree relatives, women with a history of chest irradiation between the ages of 10 and 30 years, and women with 20% or greater lifetime risk of breast cancer), annual breast MRI is indicated [46]. In cases where a breast MRI cannot be obtained, a screening breast ultrasound can be performed. Screening breast ultrasound can also be offered to women of intermediate risk or those with dense breasts who do not meet criteria for high risk. Facilities with sufficient resources could offer these additional screening studies on the same day as the mammogram, thus individualizing the service and improving patient satisfaction.

Implementation of the customer intimacy model in breast cancer screening may not be feasible in all radiology practices. Not all breast imaging facilities have the number of subspecialty mammographers that may be needed to provide immediate reads, and discussing results with patients as direct face-to-face communication can be time consuming. Furthermore, not all facilities will have the operational capability to allow flexibility in scheduling to accommodate same-day workup of patients recalled from immediate readings [36]. The reduced efficiency that may result in some practices from immediate readings may limit the ability to offer screening to all those who need it. Moreover, reducing recall rates by using performance measures to identify physicians with suboptimal performance in the interpretation of screening mammograms on the basis of physician characteristics can be challenging to implement [43].