Norwegians evaluate psychological impact of mammo recalls

2013 03 04 15 07 12 202 Woman With Pain 70

Recall after mammography is associated with transiently increased anxiety, as might be expected, but Norwegian researchers also found that four weeks after screening the level of anxiety was the same and depression was lower compared with the general population.

The psychological effects of mammography screening programs have been questioned and concerns have been raised about possible adverse effects of recall mammography, such as anxiety, worry about having breast cancer, anxiety about unfamiliar medical procedures, or severe anxiety symptomatic of psychiatric morbidity, according to Inger Schou Bredal, PhD, a researcher and associate professor in the breast and endocrine surgery department at Oslo University Hospital and the Institute of Health and Society in Norway, and colleagues (European Journal of Cancer, March 2013, Vol. 49:4, pp. 805-811).

Some observers have speculated the adverse negative psychological effect of screening could deter women from reattending subsequent screening -- especially women with false-positive results. Bredal and colleagues identified psychological distress before and after being declared healthy in women recalled for further investigation. They identified the factors associated with psychological distress and examined the women's willingness to recommend other women to undergo screening.

The study included 526 recalled women who completed a questionnaire before the recall mammogram and four weeks after receiving the results. Psychological distress was measured using the Hospital Anxiety and Depression Scale. Most patients were diagnosed without cancer (87.6% false-positive rate). Recall after mammography among women with a false-positive mammogram was associated with transiently increased anxiety and a slight increase in depression, according to the researchers.

"However, the level of anxiety was similar to and the level of depression was lower than in the general female Norwegian population," the authors wrote. "Women who received a cancer diagnosis had higher levels of anxiety and depression than the general female Norwegian population."

Nearly all the women (99%) were satisfied with their participation in the screening program; 94% thought it was important; 98% would attend the next round of screening; and 99% would recommend other women to attend.

"None of our findings surprised us," Bredal noted in an email to "It was as expected. ... The important message is that recall after mammography is associated with transiently increased anxiety."

The findings are consistent with a Norwegian study conducted in 1996-1997, which found anxiety continues to be the most prevalent association with recall mammography, but the distress of recall mammography screening is manifested in a transitory increased anxiety reaction.

"The percentage of healthy women reporting clinical depression when facing recall mammography was the same before and after being diagnosed without cancer, whereas those diagnosed with cancer had a significant increase in depression," the authors wrote. "Unlike previous studies, we did not find that women who received a final benign result (false positive) after a surgical biopsy had significantly higher anxiety level than those who received a final benign result following imaging workup."

Also, despite the pain, discomfort, and psychological impact experienced, 98% of the women in the study said they would attend subsequent rounds, showing anxiety is not a significant deterrent. Women should be informed of the possibility of being recalled, but reassured most recalled women do not have cancer, the researchers added.

Study strengths include the following:

  • The large sample
  • High response rate
  • The socioeconomic composition, which is similar to the rest of the country
  • The inclusion of a previous history of anxiety or depression
  • A comparison of distress level in the false-positive women with the general Norwegian female population

"Good communication between the health professionals and women is important and may minimize the psychological impact of recall," Bredal concluded.

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