Post Mammogram Results: All about follow-ups and call-backs

Call back and Follow-Ups

Following mammogram results after an initial breast cancer screening, there are some situations in which the doctors may ask you to return for another mammogram.

A call back should be fairly immediate.
A Follow-up is in 6 months, 1 year or 2 years.

This post has everything you need to know about call-backs and follow-ups.

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

If anything abnormal is found on the first screening mammogram, it is likely that the breast cancer unit will request a call back for additional imaging studies.

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

Medics may request a call back for something that could be totally normal, or a benign finding, so don’t panic.

But ladies, if you really have to worry,
I find it much more effective than dieting. Every cloud and all that …

Back to our latest post on Abnormal Mammmogram results and what they mean.

Initial Abnormal Mammogram Results and Call-Backs in High Risk Patients

Following initial screening, a certain percentage of women may have a higher risk for breast cancer, even if the results are clear. In the case of high risk individuals follow-ups may be necessary more frequently.

These high risk factors include:-

Women with atypical ductal hyperplasia or lobular neoplasia. If biopsy shows either of these conditions, regular screening follow-ups are very important.
A genetic predisposition for breast cancer. So, if a first or second degree family member has breast or ovarian cancer. Also, the risk increases if the family member has breast or ovarian cancer before the age of 40 years.
If a molecular exam reveals a genetic predisposition for breast cancer. So, if a woman carries the BRCA1 and/or BRCA2 mutation the risk for breast cancer increases from between 40% to 80%. Specialists recommend follow-up mammograms every 6 months to a year.

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

Now lets switch concepts to call-back again.

Following Screening Mammogram Results call backs happen right away.

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

Mammogram results mention a ‘low risk’ breast lesion. Follow-up necessary

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 suspicious lesion on subsequent mammograms, at intervals ranging from six months to a year. The number of women who receive follow-up mammogram requests will vary in different countries and districts, to a certain extent.

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

What is a ‘positive’ result?

When the radiologist reports the mammogram results, he/she might notice something and request a call-back or a follow-up. A screening radiologist has to be quite careful how his impressions are expressed and may be interpreted by the patient.

The term ‘positive result’ especially can cause a great deal of unnecessary anxiety for the patient.

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.

‘Positive’ Mammogram Results and Statistics

Ready for more confusion? Here it comes.

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’.

Screening Mammography Programs are copy-cats of each other and they all have statisticians. Somewhere, long ago, a statistician wrote a sample letter to explain mammogram results to patients. The statistician used the word ‘positive’ in the results. The same letter wording was then copied from state to state, province to province, country to country.

Furthermore, statisticians calculate accuracy using 4 values: True positives, True negatives, False positives, False negatives.

So, unless you are into statistics the word ‘positive’ is not important, right?

Exactly Moose. Some women may find this bit of geeky trivia helpful for reducing stress.

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

Specialists estimate that over a 10 year period, about one third of the women who had a ‘call-back’ for a ‘diagnostic’ (second) mammogram will have benign breast disease. So, in other words a ‘false positive’ radiologist-accuracy-statistic.

However, the more regularly a woman has breast cancer screening, for example every year or 2 years, the greater the chance of breast cancer if a call back is necessary. So, the chances of detecting breast cancer naturally increase over time with regular mammograms.

Follow-up Imaging, Anxiety and ‘no shows’

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

Factors associated with a failure to show up for 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.

Of course, the majority of these mammograms turn out to be benign breast conditions. There is no doubt that an abnormal mammogram and subsequent call back mammogram can cause an increase in anxiety for women for a long period of time. Indeed, this anxiety can continue even after the second mammogram (or biopsy) is proven to be benign, or not cancer.

What can you do to stop worrying about a call-back or follow-up?

Well, you can learn about what the follow-up or call back tests involve and when you will get the results

Follow-up imaging as an alternative to biopsy

Radiologists advocate short term follow-up mammography as a reasonable approach in the management of non-palpable breast lesions that are present on a screening mammogram. In particular, short term follow-up is useful for breast lesions that 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 important thing to remember is that
the majority of call backs following screening mammogram turn out to be benign.

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

It can be a challenge for radiologists to find a reasonable cutoff point in deciding whether a 6 month follow-up diagnostic mammogram is necessary. Secondly specialists must decide whether a biopsy is more appropriate, or not.

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

When the initial mammogram reveals an abnormality that is ‘probably benign’, then additional imaging is generally useful to help to decide whether to biopsy or not.

Specifically, the radiologist will want to determine whether the lesion is a solid mass or a cyst. In addition, the radiologist will also 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% to 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.

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% to 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.

Hope this page helps somebody. Repeat after me … ‘I’m going to be fine’.

References

Ulcickas Yood M, McCarthy BD, Lee NC, (et al). (1999) Patterns and characteristics of repeat mammography among women 50 years and older. Cancer Epidemiol Biomarkers Prev. 1999 Jul;8(7):595–599. https://www.ncbi.nlm.nih.gov/pubmed/10428196
Yabroff KR, Breen N, Vernon SW, Meissner HI, Freedman AN, Ballard-Barbash R. (2004) 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 https://www.ncbi.nlm.nih.gov/pubmed/15159302

More references for this section are on this page.