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November 24, 1993, Vol 270, No. 20 >
ARTICLE | November 24, 1993

Positive Predictive Value of Screening Mammography by Age and Family History of Breast Cancer FREE

Karla Kerlikowske, MD; Deborah Grady, MD, MPH; John Barclay, MS; Edward A. Sickles, MD; Abigail Eaton, MPH; Virginia Ernster, PhD
[+] Author Affiliations

Presented in part at the 26th annual meeting of the Society for Epidemiologic Research, Keystone, Colo, June 17, 1993.

Reprint requests to San Francisco Veterans Affairs Medical Center, General Internal Medicine Section, 111A1, 4150 Clement St, San Francisco, CA 94121 (Dr Kerlikowske).


JAMA. 1993;270(20):2444-2450. doi:10.1001/jama.1993.03510200050031
Text Size: A A A
Published online
Article
References

Objective.  —To determine the positive predictive value (PPV) of low-cost screening mammography according to age and family history of breast cancer.

Design.  —Cross-sectional.

Setting.  —Six counties in northern California.

Participants.  —A total of 31 814 women aged 30 years and older referred for mammography to the University of California, San Francisco, Mobile Mammography Screening Program from April 18, 1985, through November 20, 1992.

Measurements.  —Breast cancer risk profile, two standard mammographic views per breast, and follow-up of abnormal screening examinations.

Results.  —Although women aged 50 years or older constituted only 38.3% of all women who received first-screening mammography, 74% of breast cancers were detected in this group. Ten cancers were diagnosed per 1000 first-screening examinations in women aged 50 years or older, with 14.8 diagnostic procedures per cancer diagnosed compared with two cancers per 1000 screening examinations and 48.3 diagnostic tests per cancer diagnosed in women younger than 50 years. The PPV of first-screening mammography (number of breast cancers detected per abnormal examination) increased with age:.03 for those aged 30 to 39 years;.04 for those aged 40 to 49;.09 for those aged 50 to 59;.17 for those aged 60 to 69; and.19 for those aged 70 years or older (χ2 for trend, P<.001). Women aged 50 to 59 years had a higher PPV for first-screening mammography than women aged 40 to 49 years (.09 vs.04;P=.004), and women with a family history of breast cancer had higher PPVs compared with women without history (40 to 49 years of age,.13 vs.04, P=.01; and 50 to 59 years of age,.22 vs.09, P=.01).

Conclusion.  —Five times as many cancers per 1000 first-screening mammographic examinations were diagnosed in women aged 50 years or older compared with women aged less than 50 years. The highest PPVs for mammography were in women aged 50 years or older and in women aged 40 years or older with a family history of breast cancer. Efforts to promote screening mammography should focus on women in these groups, in whom the majority of breast cancers occur and for whom mammography has the highest PPVs.(JAMA. 1993;270:2444-2450)

REFERENCES

1 +
Centers for Disease Control and Prevention.  Public health focus: mammography. MMWR Morb Mortal Wkly Rep . 1992;;41:454-459.
2 +
O'Malley MS, Fletcher SW, Morrison B. Does Screening for Breast Cancer Save Lives? Effectiveness of Treatment After Brast Cancer Detection Following Screening by Clinical Breast Examination, Mammography and Breast Self-examination . New York, NY: Springer-Verlag New York Inc; 1990;.
3 +
Hayward RSA, Steinberg EP, Ford DE, Roizen MF, Roach KW.  Preventive care guidelines. Ann Intern Med . 1991;;114:758-783.
4 +
Woolf SH.  United States Preventive Services Task Force recommendations on breast cancer screening. Cancer . 1992;;69:1913-1918.
5 +
Tabar L, Fagerberg G, Duffy SW, Day NE, Gad A, Grontoft O.  Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am . 1992;;30:187-210.
6 +
Andersson I, Aspergren K, Janzon L, et al.  Mammographic screening and mortality from breast cancer: the Malmo Mammographic Screening Trial. BMJ . 1988;;297:943-948.
7 +
Roberts MM, Alexander FE, Anderson TJ, et al.  Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet . 1990;;335:241-246.
8 +
Frisell J, Eklund G, Hellstrom L, Lidbrink E, Rutgvist LE, Somell A.  Randomized study of mammography screening—preliminary report on mortality in the Stockholm trial. Breast Cancer Res Treatment . 1991;;18:49-56.
9 +
Miller AB, Baines CJ, To T, Wall C.  Canadian National Breast Screening Study: breast cancer detection and death rates among women aged 40 to 49 years. Can Med Assoc J . 1992;;147:1459-1476.
10 +
Shapiro S. Periodic Screening for Breast Cancer: The Health Insurance Plan Project and Its Sequelae, 1963-1986 . Baltimore, Md: The Johns Hopkins University Press; 1988;.
11 +
Nystrom L, Rutqvist LE, Wall S, et al.  Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet . 1993;;341:973-978.
12 +
Elwood JM, Cox B, Richardson AK.  The effectiveness of breast cancer screening by mammography in younger women. Online J Curr Clin Trials [serial online]. 1993;;2. Doc NR 32.
13 +
Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S.  Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst . 1993;;85:1644-1656.
14 +
Peeters PHM, Verbeek ALM, Hendriks JHCL, van Bon MJH.  Screening for breast cancer in Nijmegen: report of 6 screening rounds, 1975-1986. Int J Cancer . 1989;;43:226-230.
15 +
Sickles EA, Ominsky SH, Sollitto RA, Galvin HB, Monticciolo DL.  Medical audit of a rapid-throughput mammography screening practice: methodology and results of 27 114 examinations. Radiology . 1990;;175:323-327.
16 +
Stacey-Clear A, McCarthy HA, Hall DA, et al.  Breast cancer survival among women under age 50: is mammography detrimental? Lancet . 1992;;340: 991-994.
17 +
Costanza ME.  Breast cancer screening in older women. Cancer . 1992;;69:1925-1931.
18 +
Hurley SF, Kaldor JM.  The benefits and risks of mammographic screening for breast cancer. Epidemiol Rev . 1992;;14:101-130.
19 +
Ciatto S, Cecchini S, Del Turco MR, Grazzini G, Iossa A, Bartoli D.  Referral policy and positive predictive value of call for surgical biopsy in the Florence Breast Cancer Screening Program. J Clin Epidemiol . 1990;;43:419-423.
20 +
de Waard F, Collette HJA, Rombach JJ, Baanders-Van Halewijn EA, Honing C.  The DOM project for the early detection of breast cancer, Utrecht, the Netherlands. J Chronic Dis . 1984;;37:1-44.
21 +
Collette HJA, Rombach JJ, de Waard F, Collette C.  An update of the DOM project for the early detection of breast cancer.  In: Day NE, Miller AB, eds. Screening for Breast Cancer . Toronto, Ontario: Hans Huber; 1988;:17-27.
22 +
Miller AB, Bafnes CJ, To T, Wall C.  Canadian National Breast Screening Study, 2: breast cancer detection and death rates among women aged 50 to 59 years. Can Med Assoc J . 1992;;147:1477-1488.
23 +
Dershaw DD, Liberman L, Lippin BS.  Mobile mammographic screening of self-referred women: results of 22 540 screenings. Radiology . 1992;;184: 415-419.
24 +
Bird RE.  Low-cost screening mammography: report on finances and review of 21 716 consecutive cases. Radiology . 1989;;171:87-90.
25 +
Goodno JA.  Breast cancer detection: experience in a suburban community. Am J Obstet Gynecol . 1990;;162:1393-1397.
26 +
Reinig JW, Strait CJ.  Professional mammographic quality assessment program for a community hospital. Radiology . 1991;;180:393-396.
27 +
Linver MN, Paster SB, Rosenberg RD, Key CR, Stidley CA, King WV.  Improvement in mammography interpretation skills in a community radiology practice after dedicated teaching courses: 2-year medical audit of 38633 cases. Radiology . 1992;;184:39-43.
28 +
Kopans DB.  Screening mammography in women over age 65. J Gerontol . 1992;;47:59-62.
29 +
Warren DL, Stelling CB.  Sensitivity, specificity, predictive value and accuracy of film/screen mammography a three-year experience. J Ky Med Assoc . 1989;;87:169-173.
30 +
UK Trial of Early Detection of Breast Cancer Group.  First results on mortality reduction in the UK Trial of Early Detection of Breast Cancer. Lancet . 1988;;2:411-416.
31 +
Sickles EA, Weber WN, Galvin HB, Ominsky SH, Sollitto RA.  Mammographic screening: how to operate successfully at low cost. Radiology . 1986;; 160:95-97.
32 +
Sickles EA.  The use of computers in mammography screening. Radiol Clin North Am . 1987;;25: 1015-1030.
33 +
Monticciolo DL, Sickles EA.  Computerized follow-up of abnormalities detected at mammography screening. AJR Am J Roentgenol . 1990;;155:751-753.
34 +
American Joint Committee on Cancer. Manual for Staging of Cancer . 3rd ed. Philadelphia, Pa: JB Lippincott; 1988;.
35 +
Pillsbury SG, Link JS, Roux S.  Improved mammographic accuracy. Obstet Gynecol . 1991;;164:1643-1646.
36 +
Rubin E, Frank MS, Stanley RJ, Bernreuter WK, Han SY.  Patient-initiated mobile mammography: analysis of the patients and the problems. South Med J . 1990;;83:178-184.
37 +
Alghisi A, Donato F, Lucini L, et al.  Breast cancer screening in an urban population in northern Italy. Tumori . 1990;;76:22-25.
38 +
Verbeek ALM, van den Ban MC,  Hendriks JHCL. A proposal for short-term quality control in breast cancer screening. Br J Cancer . 1991;;63:261-264.
39 +
Lerman C, Trock B, Rimer BK, Boyce A, Jepson C, Engstrom PF.  Psychological and behavioral implications of abnormal mammograms. Ann Intern Med . 1991;;114:657-661.
40 +
The Surveillance Program, Division of Cancer Prevention and Control. Cancer Statistics Review 1973-87 . Washington, DC: National Cancer Institute; 1988;. Publication 90-2789.
41 +
Harris JR, Lippman ME, Veronesi U, Willett W.  Breast cancer. N Engl J Med . 1992;;327:319-328.
42 +
Colditz GA, Willett WC, Hunter DJ, et al.  Family history, age, and risk of breast cancer: prospective data from the Nurses' Health Study. JAMA . 1993;;270:338-343.
43 +
Kopans DB.  The positive predictive value of mammography. AJR Am J Roentgenol . 1992;;158: 521-526.
44 +
Sickles EA.  Quality assurance: how to audit your own practice. Radiol Clin North Am . 1992;; 30:265-275.
45 +
Ketcham AS, Moffat FL.  Vexed surgeons, perplexed patients, and breast cancers which may not be cancer. Cancer . 1990;;65:387-393.
46 +
Page DL, Dupont WD, Rogers LW, et al.  Intraductal carcinoma of the breast: follow-up after biopsy only. Cancer . 1982;;49:751-758.
47 +
Farrow JH.  Current concepts in the detection of the earliest of the early breast cancers. Cancer . 1970;;25:468-477.
48 +
Lagios MD, Margolin FR, Westdahl PR, Rose MR.  Mammographically detected duct carcinoma in situ: frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence. Cancer . 1989;;63:618-624.
49 +
Arnesson LG, Smeds S, Fagerberg G, et al.  Follow-up of two treatment modalities for ductal cancer in situ of the breast. Br J Surg . 1989;;76: 672-675.
50 +
Harris RP, Fletcher SW, Gonzalez JJ, et al.  Mammography and age: are we targeting the wrong women? Cancer . 1991;;67:2010-2014.
51 +
Centers for Disease Control. Use of mammography for breast cancer screening: Rhode Island, 1987. MMWR Morb Mortal Wkly Rep . 1988;;37:357-360.
52 +
The NCI Breast Cancer Screening Consortium.  Screening mammography: a missed clinical opportunity? results of the NCI Breast Cancer Screening Consortium and National Health Interview Survey studies. JAMA . 1990;;264:54-58.
53 +
Humphrey LL, Ballard DJ.  Screening mammography. West J Med . 1988;;149:95-97.
54 +
Fox SA, Murata PJ, Stein JA.  The impact of physician compliance on screening mammography for older women. Arch Intern Med . 1991;;151:50-56.
55 +
California Department of Finance.  Special population summary from 1993 baseline population projections.  In: Cancer Incidence and Mortality by Race/Ethnicity in California, 1988-90 . Sacramento: California Department of Health Services; March 1993;.
56 +
Kuni CC.  Mammography in the 1990s: a plea for objective doctors and informed patients. Am J Prev Med . 1993;;9:185-190.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Centers for Disease Control and Prevention.  Public health focus: mammography. MMWR Morb Mortal Wkly Rep . 1992;;41:454-459.
2 +
O'Malley MS, Fletcher SW, Morrison B. Does Screening for Breast Cancer Save Lives? Effectiveness of Treatment After Brast Cancer Detection Following Screening by Clinical Breast Examination, Mammography and Breast Self-examination . New York, NY: Springer-Verlag New York Inc; 1990;.
3 +
Hayward RSA, Steinberg EP, Ford DE, Roizen MF, Roach KW.  Preventive care guidelines. Ann Intern Med . 1991;;114:758-783.
4 +
Woolf SH.  United States Preventive Services Task Force recommendations on breast cancer screening. Cancer . 1992;;69:1913-1918.
5 +
Tabar L, Fagerberg G, Duffy SW, Day NE, Gad A, Grontoft O.  Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am . 1992;;30:187-210.
6 +
Andersson I, Aspergren K, Janzon L, et al.  Mammographic screening and mortality from breast cancer: the Malmo Mammographic Screening Trial. BMJ . 1988;;297:943-948.
7 +
Roberts MM, Alexander FE, Anderson TJ, et al.  Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet . 1990;;335:241-246.
8 +
Frisell J, Eklund G, Hellstrom L, Lidbrink E, Rutgvist LE, Somell A.  Randomized study of mammography screening—preliminary report on mortality in the Stockholm trial. Breast Cancer Res Treatment . 1991;;18:49-56.
9 +
Miller AB, Baines CJ, To T, Wall C.  Canadian National Breast Screening Study: breast cancer detection and death rates among women aged 40 to 49 years. Can Med Assoc J . 1992;;147:1459-1476.
10 +
Shapiro S. Periodic Screening for Breast Cancer: The Health Insurance Plan Project and Its Sequelae, 1963-1986 . Baltimore, Md: The Johns Hopkins University Press; 1988;.
11 +
Nystrom L, Rutqvist LE, Wall S, et al.  Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet . 1993;;341:973-978.
12 +
Elwood JM, Cox B, Richardson AK.  The effectiveness of breast cancer screening by mammography in younger women. Online J Curr Clin Trials [serial online]. 1993;;2. Doc NR 32.
13 +
Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S.  Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst . 1993;;85:1644-1656.
14 +
Peeters PHM, Verbeek ALM, Hendriks JHCL, van Bon MJH.  Screening for breast cancer in Nijmegen: report of 6 screening rounds, 1975-1986. Int J Cancer . 1989;;43:226-230.
15 +
Sickles EA, Ominsky SH, Sollitto RA, Galvin HB, Monticciolo DL.  Medical audit of a rapid-throughput mammography screening practice: methodology and results of 27 114 examinations. Radiology . 1990;;175:323-327.
16 +
Stacey-Clear A, McCarthy HA, Hall DA, et al.  Breast cancer survival among women under age 50: is mammography detrimental? Lancet . 1992;;340: 991-994.
17 +
Costanza ME.  Breast cancer screening in older women. Cancer . 1992;;69:1925-1931.
18 +
Hurley SF, Kaldor JM.  The benefits and risks of mammographic screening for breast cancer. Epidemiol Rev . 1992;;14:101-130.
19 +
Ciatto S, Cecchini S, Del Turco MR, Grazzini G, Iossa A, Bartoli D.  Referral policy and positive predictive value of call for surgical biopsy in the Florence Breast Cancer Screening Program. J Clin Epidemiol . 1990;;43:419-423.
20 +
de Waard F, Collette HJA, Rombach JJ, Baanders-Van Halewijn EA, Honing C.  The DOM project for the early detection of breast cancer, Utrecht, the Netherlands. J Chronic Dis . 1984;;37:1-44.
21 +
Collette HJA, Rombach JJ, de Waard F, Collette C.  An update of the DOM project for the early detection of breast cancer.  In: Day NE, Miller AB, eds. Screening for Breast Cancer . Toronto, Ontario: Hans Huber; 1988;:17-27.
22 +
Miller AB, Bafnes CJ, To T, Wall C.  Canadian National Breast Screening Study, 2: breast cancer detection and death rates among women aged 50 to 59 years. Can Med Assoc J . 1992;;147:1477-1488.
23 +
Dershaw DD, Liberman L, Lippin BS.  Mobile mammographic screening of self-referred women: results of 22 540 screenings. Radiology . 1992;;184: 415-419.
24 +
Bird RE.  Low-cost screening mammography: report on finances and review of 21 716 consecutive cases. Radiology . 1989;;171:87-90.
25 +
Goodno JA.  Breast cancer detection: experience in a suburban community. Am J Obstet Gynecol . 1990;;162:1393-1397.
26 +
Reinig JW, Strait CJ.  Professional mammographic quality assessment program for a community hospital. Radiology . 1991;;180:393-396.
27 +
Linver MN, Paster SB, Rosenberg RD, Key CR, Stidley CA, King WV.  Improvement in mammography interpretation skills in a community radiology practice after dedicated teaching courses: 2-year medical audit of 38633 cases. Radiology . 1992;;184:39-43.
28 +
Kopans DB.  Screening mammography in women over age 65. J Gerontol . 1992;;47:59-62.
29 +
Warren DL, Stelling CB.  Sensitivity, specificity, predictive value and accuracy of film/screen mammography a three-year experience. J Ky Med Assoc . 1989;;87:169-173.
30 +
UK Trial of Early Detection of Breast Cancer Group.  First results on mortality reduction in the UK Trial of Early Detection of Breast Cancer. Lancet . 1988;;2:411-416.
31 +
Sickles EA, Weber WN, Galvin HB, Ominsky SH, Sollitto RA.  Mammographic screening: how to operate successfully at low cost. Radiology . 1986;; 160:95-97.
32 +
Sickles EA.  The use of computers in mammography screening. Radiol Clin North Am . 1987;;25: 1015-1030.
33 +
Monticciolo DL, Sickles EA.  Computerized follow-up of abnormalities detected at mammography screening. AJR Am J Roentgenol . 1990;;155:751-753.
34 +
American Joint Committee on Cancer. Manual for Staging of Cancer . 3rd ed. Philadelphia, Pa: JB Lippincott; 1988;.
35 +
Pillsbury SG, Link JS, Roux S.  Improved mammographic accuracy. Obstet Gynecol . 1991;;164:1643-1646.
36 +
Rubin E, Frank MS, Stanley RJ, Bernreuter WK, Han SY.  Patient-initiated mobile mammography: analysis of the patients and the problems. South Med J . 1990;;83:178-184.
37 +
Alghisi A, Donato F, Lucini L, et al.  Breast cancer screening in an urban population in northern Italy. Tumori . 1990;;76:22-25.
38 +
Verbeek ALM, van den Ban MC,  Hendriks JHCL. A proposal for short-term quality control in breast cancer screening. Br J Cancer . 1991;;63:261-264.
39 +
Lerman C, Trock B, Rimer BK, Boyce A, Jepson C, Engstrom PF.  Psychological and behavioral implications of abnormal mammograms. Ann Intern Med . 1991;;114:657-661.
40 +
The Surveillance Program, Division of Cancer Prevention and Control. Cancer Statistics Review 1973-87 . Washington, DC: National Cancer Institute; 1988;. Publication 90-2789.
41 +
Harris JR, Lippman ME, Veronesi U, Willett W.  Breast cancer. N Engl J Med . 1992;;327:319-328.
42 +
Colditz GA, Willett WC, Hunter DJ, et al.  Family history, age, and risk of breast cancer: prospective data from the Nurses' Health Study. JAMA . 1993;;270:338-343.
43 +
Kopans DB.  The positive predictive value of mammography. AJR Am J Roentgenol . 1992;;158: 521-526.
44 +
Sickles EA.  Quality assurance: how to audit your own practice. Radiol Clin North Am . 1992;; 30:265-275.
45 +
Ketcham AS, Moffat FL.  Vexed surgeons, perplexed patients, and breast cancers which may not be cancer. Cancer . 1990;;65:387-393.
46 +
Page DL, Dupont WD, Rogers LW, et al.  Intraductal carcinoma of the breast: follow-up after biopsy only. Cancer . 1982;;49:751-758.
47 +
Farrow JH.  Current concepts in the detection of the earliest of the early breast cancers. Cancer . 1970;;25:468-477.
48 +
Lagios MD, Margolin FR, Westdahl PR, Rose MR.  Mammographically detected duct carcinoma in situ: frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence. Cancer . 1989;;63:618-624.
49 +
Arnesson LG, Smeds S, Fagerberg G, et al.  Follow-up of two treatment modalities for ductal cancer in situ of the breast. Br J Surg . 1989;;76: 672-675.
50 +
Harris RP, Fletcher SW, Gonzalez JJ, et al.  Mammography and age: are we targeting the wrong women? Cancer . 1991;;67:2010-2014.
51 +
Centers for Disease Control. Use of mammography for breast cancer screening: Rhode Island, 1987. MMWR Morb Mortal Wkly Rep . 1988;;37:357-360.
52 +
The NCI Breast Cancer Screening Consortium.  Screening mammography: a missed clinical opportunity? results of the NCI Breast Cancer Screening Consortium and National Health Interview Survey studies. JAMA . 1990;;264:54-58.
53 +
Humphrey LL, Ballard DJ.  Screening mammography. West J Med . 1988;;149:95-97.
54 +
Fox SA, Murata PJ, Stein JA.  The impact of physician compliance on screening mammography for older women. Arch Intern Med . 1991;;151:50-56.
55 +
California Department of Finance.  Special population summary from 1993 baseline population projections.  In: Cancer Incidence and Mortality by Race/Ethnicity in California, 1988-90 . Sacramento: California Department of Health Services; March 1993;.
56 +
Kuni CC.  Mammography in the 1990s: a plea for objective doctors and informed patients. Am J Prev Med . 1993;;9:185-190.

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