Post mammogram follow-up or call-back

Following an initial breast cancer screening mammogram, there are some situations in which a woman may be asked to return for an extra mammogram.

Megan Megan
What is a follow-up and what is a call-back?


Dr. Halls Dr. Halls
These words used for screening, create confusion.



 
 

  • A call back is supposed to happen soon.
  • A Follow-up is in 1 year, or 6 months, or 2 years.

This page is about call-backs. Then follow-ups. Then call backs again, follow-up, etc.

(By the way, the first mammogram would be the screening mammogram, and the extra views they get when you return, might be called a “diagnostic” mammogram spot view.)

If something abnormal is found on the first mammogram, it is likely that a woman will be called back for additional imaging studies.

  • What does mammogram call back mean? It means they want extra views or ultrasound. Keep reading.
  • What happens at mammogram call back and why? They give you snacks and take blood. No, wait, I’m confused.

Talking Moose

You can be called back for something that could be a totally normal or a benign finding, so don’t panic, at least for a few more paragraphs.

breast mammogram X-ray

Talking Moose
Talking Moose
This picture is a mammogram.


Dr. Halls Dr. Halls
Lets switch briefly to talk about a follow-up concept



 
 

Women with BRCA1 and BRCA2 variants, family history of breast cancer, or atypical ductal hyperplasia or lobular hyperplasia should have a shorter follow-up mammogram interval

Following the initial screening, there will be a certain percentage of women who may be considered as having a higher risk, even if the results are clear. Women with atypical ductal hyperplasia or lobular neoplasia, as revealed by surgical biopsy, should naturally be re-screened at regular intervals. Also, women with a high probability of having a having a cancer-predisposed gene are at higher risk. For example, if there is breast cancer or ovarian cancer in first or second degree family members, especially occurring before the age of 40, or if a women has a genetic predisposition as revealed with a molecular exam, then there ought to be close follow-up. It is also estimated that women who carry the BRCA1 and BRCA2 mutations are at an increased risk for breast cancer development with risk estimates ranging from 40%-80%. These individuals would likely be recommended for follow-up mammograms every 6 months to 1 year.

Dr. Halls Dr. Halls
See that? An example of risk, and a follow-up interval of 6 months or a year.


Talking Moose
Talking Moose
Now lets switch concept to call-back again.



 
 

Diagnostic call back mammograms generally happen right away.

You get a letter or a phone call, asking you to return. It makes you nervous.

Dr. Halls Dr. Halls
Switching concept again, to follow-up.



 
 

Mammogram mentioned a low risk breast lesion, the next mammogram is for observation over time passing.

You get a mammogram results letter, saying they want to re-check something in 6 months. It makes you nervous.

Quite often the most prudent measure for a very low risk finding is simply to ‘observe’ the suspected lesion on subsequent mammograms, at intervals ranging from six months to a year, generally. The number of women asked to return for a follow-up mammogram will vary in different countries and districts to a certain extent.

Holly Holly
I’ve got it. Return soon means it’s a call-back. 6 months or longer is a follow-up.



 
 

What is a ‘positive’ result?

When the radiologist reports the mammogram, he/she might notice something and want a call-back. A screening radiologist has to be quite careful how impressions are interpreted and expressed, when requesting a call-back or a follow-up mammogram. A great deal of unnecessary anxiety can be caused by the term ‘positive result’ on a screening mammogram report.

Tanya Tanya
Yes, I would be nervous if ‘positive result’ was wording on a mammogram letter.



 
 

If the initial mammogram radiologist noticed ‘something‘ that needs further clarification, the radiologist will usually request typical call-back procedures such as magnification, ultrasound, and maybe a biopsy.

Talking Moose
Talking Moose
Ready for more confusion? Here it comes.


Dr. Halls Dr. Halls
The word ‘positive’, on mammogram letters, is for STATISTICS.



 
 

If you see the word ‘positive‘ on a mammogram report, and its a ‘call-back’, the word ‘positive’ is for STATISTICS. The statisticians want to score ‘true positive’ and ‘false positive’.

Gretchen Gretchen
I’m not a statistician, so I will ignore the word ‘positive’.


Dr. Halls Dr. Halls
Yes, good idea.



 
 

SIDEBAR DISCUSSION. Screening Mammography Programs, are copy-cats of each other, and they all have statisticians. Somewhere long ago, a statistician helped write up a sample letter to explain mammogram results to patients, and they put the words ‘positive’ into it. The same letter wording then copied from state to state, province to province, country to country.

 

SIDEBAR TRIVIA. Statisticians calculate accuracy using 4 values: True positives, True negatives, False positives, False negatives.

 

The likelihood of ‘diagnostic’ call back mammograms being breast cancer increases over the years of annual breast cancer screening

It is estimated that over a 10 year period, about one third of the women who were ‘called-back’ for a ‘diagnostic’ (second) mammogram will have benign breast disease, or in other words a ‘false positive’ radiologist-accuracy-statistic.

However, these are statistics taken over time, with annual or biannual mammograms. When a women is called back for a follow-up mammogram after several years of regular breast cancer screening, the chances of abnormal findings actually being indicative of breast cancer will naturally increase.

(This paragraph above is true, confusing, and not really important, unless two statisticians are arguing with each other over beers.)

Follow-up imaging unfortunately often create high levels of anxiety for breast cancer, and ‘no shows’

About 9% of women who have something abnormal on their first mammogram still do not show up, do not return, for call-back or follow-up mammograms, which is unfortunate.

Factors associated with failure to complete a subsequent mammogram include low socio-economic status and low levels of formal education.

Women who perceive a higher than average level of cancer in their extended family tend to be the most motivated to attend a follow-up mammogram.

But there can still be anxiety associated with a call-back or follow-up mammogram. About 26% of women asked to return for a mammogram or ultrasound workup after the initial breast cancer screening, express high anxiety over the possibility of breast cancer.

Betty Betty
Is there anything we can do to remove that anxiety?


Talking Moose
Talking Moose
Imagine Kittens?


Hector Hector
Surprise party?


Gretchen Gretchen
Neither of those, but you will relax, am I right?



 
 

Of course, a majority of these mammograms turn out to be benign breast things. There is no doubt that an abnormal mammogram and subsequent call back mammogram can cause increased anxiety for women for an extended period of time, even after the second mammogram (or biopsy) is confirmed to be not cancer.

Follow-up imaging is often a sensible alternative to biopsy in low risk breast lesions.

Short term follow-up mammography has long been advocated as a reasonable approach in the management of non-palpable breast lesions detected on a breast cancer screening mammogram, and in particular for those breast lesions which appear ‘likely benign’ due to their imaging characteristics.

The alternative would be to request a biopsy sample from the patient, and in most all cases a needle biopsy would be sufficient. But in general the cost savings of a follow-up mammogram instead of a biopsy for ‘probably benign’ breast lesions is considerable. Biopsy is more expensive.

The thing to remember is, by a vast majority, lesions detected by the initial breast cancer screening mammography, and called-back, are in fact benign.

The ‘thresholds’ for requesting follow-up imaging, or biopsy can be difficult to gauge

It can be a challenge to find reasonable and balanced cutoff points in deciding first whether a 6 month follow-up diagnostic mammogram is even warranted, and secondly whether or not a biopsy should be used instead.

Generally speaking, if the first screening mammography results are interpreted as ‘highly suggestive of malignancy’, then a core-needle biopsy should probably be the next step.

When the initial mammogram reveals an abnormality that is interpreted as ‘probably benign’, then additional imaging is generally required in order to decide whether to biopsy or not.

Specifically, the radiologist will want to determine whether the lesion is a solid mass or more of a cyst, and will also probably want to take a closer look at the margins. If all indications of the second imaging studies are for a benign or likely benign lesion, then subsequent follow up imaging studies in about 6 months is probably a reasonable approach, without the necessity of a biopsy.

Over 90% of screening mammograms do not require follow-up ‘diagnostic’ imaging

About 92% of screening mammograms do not require additional follow-up imaging. One cannot generalize about the number of follow-up mammograms that will require biopsy, as this totally depends upon the specifics of the lesion in each individual case. However, it can be stated that about 60%-70% of women who go through a call-back diagnostic mammogram or ultrasound, and, have imaging features abnormal enough to require a biopsy, will turn out to have benign breast disease only. Lets say, only about 30% of women receiving a call-back, may have breast cancer.

A request for follow-up ultrasound alone tends to be less serious, statistically

One should not over-analyze the steps taken by the screening and diagnostic team. The evaluative procedures for breast cancer are well documented and basically standardized, and the physicians will only be asking for prudent diagnostic measures. However, it is fair to say that:

  • If only a follow-up ultrasound is requested, the radiologist is in most cases pretty sure that it is not breast cancer (most likely a cyst), and only about 12%-17% of these suspicious lesions turn out to be breast cancer.
  • If the diagnostic call-back letter asks for a second mammogram as well as ultrasound, the lesion turns out to be breast cancer about 20% of the time.
  • When the doctors request a call-back diagnostic mammogram, and an ultrasound, and a biopsy, the suspicious mass turns out to be breast cancer about 37% of the time.

Talking Moose
Talking Moose
Are these the probabilities of cancer you were wondering about? (above)



 
 

References

  1. Yabroff KR, Breen N, Vernon SW, Meissner HI, Freedman AN, Ballard-Barbash R. What factors are associated with diagnostic follow-up after abnormal mammograms? Findings from a U.S. National Survey. Cancer Epidemiol Biomarkers Prev. 2004 May;13(5):723-32
  2. Fair, AM., Wujcik, D., Lin, JNS., Zheng, W., Egan, KM., Grau, AM., Champion, VL., Wallston, KA. Psychosocial Determinants of Mammography Follow-up after Receipt of Abnormal Mammography Results in Medically Underserved Women. J Health Care Poor Underserved. 2010 February; 21(1 Suppl): 71–94.
  3. Ulcickas Yood M, McCarthy BD, Lee NC, et al. Patterns and characteristics of repeat mammography among women 50 years and older. Cancer Epidemiol Biomarkers Prev. 1999 Jul;8(7):595–599.
  4. Buseman S, Mouchawar J, Calonge N, et al. Mammography screening matters for young women with breast carcinoma: evidence of downstaging among 42–49-year-old women with a history of previous mammography screening. Cancer. 2003 Jan 15;97(2):352–358.
  5. Powe BD, Hamilton J, Brooks P. Perceptions of cancer fatalism and cancer knowledge: a comparison of older and younger African American women. J Psychosoc Oncol. 2006;24(4):1–13.
  6. Brown Sofair J, Lehlbach M. The role of anxiety in a mammography screening program.Psychosomatics. 2008 Jan-Feb;49(1):49-55.
  7. Brenner RJ.Short-term follow-up recommendations after preoperative breast MR assessment for breast cancer diagnosis: are we lacking a rational basis? Radiology. 2010 Oct;257(1):18-21.
  8. Elmore, JG., Barton, MB. Moceri, VM, Polk, S., Arena, PJ., Fletcher, SW., Ten-Year Risk of False Positive Screening Mammograms and Clinical Breast Examinations. N Engl J Med 1998; 338:1089-1096
  9. Brown ML, Houn F, Sickles EA, Kessler LG. Screening mammography in community practice: positive predictive value of abnormal findings and yield of follow-up diagnostic procedures. AJR Am J Roentgenol 1995;165:1373-1377
  10. Ellman R, Angeli N, Christians A, Moss S, Chamberlain J, Maguire P. Psychiatric morbidity associated with screening for breast cancer. Br J Cancer 1989;60:781-784
  11. Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. Likelihood ratios for modern screening mammography: risk of breast cancer based on age and mammographic interpretation. JAMA 1996;276:39-43
  12. Grady, D., Smith-Bindman, R., Kerlikowske, K., Ljung, BM. Evaluation of abnormal mammography results and palpable breast abnormalities. Annals of Internal Medicine (2003) vol. 139 no. 4 274-284
  13. Carney PA, Abraham LA, Miglioretti DL, Yabroff KR, Sickles EA, Buist DS, Kasales CJ, Geller BM, Rosenberg RD, Dignan MB, Weaver DL, Kerlikowske K; Breast Cancer Surveillance Consortium. Factors associated with imaging and procedural events used to detect breast cancer after screening mammography. AJR Am J Roentgenol. 2007 Feb;188(2):385-92.
  14. Ready, KJ., Gutierrez-Barrera, AM., Atchley, D., Soloman, KK., Amos, C., Meric-Bernstam, F., Lu, KH., Hortobagyi, GN., Arun, B., Cancer risk management decisions of women with BRCA variants of uncertain significance. J Clin Oncol 26: 2008 (May 20 suppl)
  15. Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, Morris E, Pisano E, Schnall M, Sener S, Smith RA, Warner E, Yaffe M, Andrews KS, Russell CA; American Cancer Society Breast Cancer Advisory Group.American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography.CA Cancer J Clin. 2007 Mar-Apr;57(2):75-89.
  16. Mincey, BA., Genetics and the Management of Women at High Risk for Breast Cancer. The Oncologist, (2003)Vol. 8, No. 5, 466–473
  17. Burke W, Daly M, Garber J et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer. II. BRCA1 and BRCA2. Cancer Genetics Studies Consortium. JAMA 1997;277:997–1003

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