Mammographic Screening Discomfort Does not Deter Majority of Women From Future Screening Examination
Abstract & Commentary
Synopsis: Aspects regarding the perceived level of discomfort by 933 women undergoing routine screening mammography were assessed by telephone interviews conducted at a median of three weeks after the examination and analyzed with respect to various factors and effect on future compliance.
Source: Dullum JR, et al. Rates and correlates of discomfort associated with mammography. Radiology 2000;214:547-552.
Women were recruited into this telephone interview study following permission by participating physicians, with a 50% recruitment rate of 933 women from a total pool of 1863. Women underwent mammography at one of six different facilities in San Diego County in southern California. The population studied included a relatively high percentage of Latino women whose compliance with mammography has been previously reported as low and who have not been included in substantial numbers in prior reports.
The mean age studied was 60 years, and the majority of women surveyed were non-Latino white with a relatively high educational and income level status. About 32% had been told by their physician they had fibrocystic disease. The specific elements of analysis included a) perceived discomfort (not pain) from mammography; b) satisfaction with the care received during study-entry mammography (3 items); c) intentions to undergo mammography the following year; d) number of prior mammographic examinations; e) fibrocystic breast status; f) age; g) educational level; h) ethnicity; and i) annual family income level.
In contrast to prior reports, more than half of the women (51.8%) reported moderate or greater physical discomfort, even though most felt confident that the exam was performed properly and did not think the technologist too rough in the performance of the examination. Higher dissatisfaction was noted for women in lower income levels, lower educational status, and those without a diagnosis of fibrocystic disease. A significant association of discomfort related to the individual facility (38%-60%). Intention to undergo repeat mammography, however, was not correlated with this high level of discomfort.
Dullum and colleagues acknowledge limitations of the study. Unlike prior studies using exit interview questionnaires, this methodology was based on a telephone interview conducted with a median of three weeks delay. Most of the women were undergoing regular screening mammography and were of a higher socioeconomic status. The study did not attempt, as others have, to identify different constructs of pain and discomfort, relying on other data that suggest these scales are highly correlated.
COMMENT by R. James Brenner, MD
This is the second largest study on this topic and one of three using multiple sites for recruitment. Although psychosocial components of any imaging examination need to be considered by the radiologist—an admonition well known to pediatric specialists—this issue is particularly relevant to those in breast imaging, including physicians and administrators. Given the high volume of asymptomatic women invited into screening mammography programs—and encouraged to do so by several elements in society as part of a public health campaign—the time-consuming issues involved with patient satisfaction are almost as tantamount in importance from an administrative point of view as the science itself. Whether the facility participates in HEDIS survey analyses or conducts its own internal audits, patient complaints regarding the performance of mammography consume a disproportionate amount of resources compared to other modalities. This phenomenon may be secondary to the fact that screening mammography is directed to well women, whereas patients with symptoms or signs of disease are more prepared to undergo diagnostic examinations with a temperament that may tolerate more discomfort. By comparison, historical screening with chest radiography is a painless event.
In fact, reasonably vigorous compression is an important component of the examination, as initially advocated by a female mammographer more than 25 years ago. Radiologists and administrators will be relieved, if not heartened, to review the results of this survey, which was undertaken not by physicians but by authors with a background in public health. Those reviewing patient satisfaction surveys will not find themselves in the position of a pariah when they identify a higher than previously reported incidence of discomfort with the examination. Rather, the encouraging conclusion that such discomfort does not interfere with future compliance will reinforce the resolve to obtain high-quality images. Will there still be an average three to five hate letters a year when examining a population of 10,000? Probably. But the majority of women will not be deterred by an uncomfortable examination from seeking continued mammographic screening. The caveat must be recognized that the interviews took place at some time after the exam, when immediate reaction may not have been as severe as an exit interview. Nonetheless, in looking at long-term response and compliance, this issue does not obviate the conclusions.
Can this study be reconciled with other reports indicating a greater importance on direct physician referral as being a predisposing factor in compliance as well as the low compliance rate among the Latino population? Not necessarily. Physician involvement was a part of this methodology. Latino women, while constituting an increased percentage of those studied, were still a small fraction. Finally, a majority of these women had been undergoing regular screening mammography so that they have been more conditioned to the type of examination and, thus, reflect a group of women who tolerate the discomfort without abandoning the process. Thus, the relationship in this study between compliance and discomfort is difficult to establish among a self-selected population. Nonetheless, the study does put into perspective the unfavorable nature of the mammographic examination as not necessarily deterring women from seeking appropriate screening.
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