Psychosocial consequences of false-positive screening results - breast cancer as an example

John Brodersen MD, GP, PhD

The Department of General PracticeInstitute of Public Health

Centre of Health and SocietyUniversity of Copenhagen

Psychosocial consequences of false-positive screening results - breast cancer as an example 2

Content of presentation

Medical screening Breast cancer screening Psychosocial consequences Conclusions and perspectives

Psychosocial consequences of false-positive screening results - breast cancer as an example 3

Content of presentation

Medical screening Breast cancer screening Psychosocial consequences Conclusions and perspectives

Psychosocial consequences of false-positive screening results - breast cancer as an example 4

Screening the coal

Psychosocial consequences of false-positive screening results - breast cancer as an example 5

Outcome of medical screening

Disease

Healthy

Positive screening result

True positive False positive

Negative screening result

False negative True negative

Psychosocial consequences of false-positive screening results - breast cancer as an example 6

Outcome of medical screening

Disease

Healthy

Positive screening result

True positive

False positive ‘False alarm’

Negative screening result

False negative

True negative

Psychosocial consequences of false-positive screening results - breast cancer as an example 7

Outcome of medical screening

Healthy

Disease

Arbitrary scale

Psychosocial consequences of false-positive screening results - breast cancer as an example 8

Content of presentation

Medical screening Breast cancer screening Psychosocial consequences Conclusions and perspectives

Psychosocial consequences of false-positive screening results - breast cancer as an example 9

Proportion

2,000 women, age 50 – 69, screened every second year for 10 years – 5 rounds:

1 death of breast cancer prevented> 200 false-positive result

1:200

P. C. Gotzsche and M. Nielsen. Screening for breast cancer with mammography. Cochrane Database.Syst.Rev. (4):CD001877, 2006.

Psychosocial consequences of false-positive screening results - breast cancer as an example 10

Content of presentation

Medical screening Breast cancer screening Psychosocial consequences Conclusions and perspectives

Psychosocial consequences of false-positive screening results - breast cancer as an example 11

Adequacy of measurement

23 studies identified Most commonly used measures:

The General Health Questionnaire (GHQ)The Hospital Anxiety and Depression Scale (HADS)The Psychological Consequences Questionnaire (PCQ)The State-Trait Anxiety Inventory (STAI)

These 4 measures used in 17 studies

Brodersen J., Thorsen H., Cockburn J. The adequacy of measurement of short and long term consequences of false-positive screening mammography. Review. Journal of Medical Screening 11 (1):39-44. 2004.

Psychosocial consequences of false-positive screening results - breast cancer as an example 12

Focus groups - content validity

Examinations Ultrasound & clini-cal mammography

Plus needle biopsy

Plus surgical biopsy

No. of women 5 7 7

Mean age 58.2 58.7 55.8

Examinations Plus earlyrecall

Plus needlebiopsy

Plus surgical biopsy

No. of women 5 5 7

Mean age 59.6 53.6 57.7

J. Brodersen and H. Thorsen. Consequences Of Screening in Breast Cancer (COS-BC): development of a questionnaire. Scand.J Prim.Health Care 26 (4):251-256, 2008.

Psychosocial consequences of false-positive screening results - breast cancer as an example 13

Result from interviews

Part I: 33 items on negative psychosocial consequences

At invitationAt screeningAfter diagnosis

Part II: 13 items on long-term psychosocial consequences

After diagnosisJ. Brodersen and H. Thorsen. Consequences Of Screening in Breast Cancer (COS-BC): development of a questionnaire. Scand.J Prim.Health Care 26 (4):251-256, 2008.

Psychosocial consequences of false-positive screening results - breast cancer as an example 14

Statistical methods

ReliabilityCronbach’s alphaPerson Separation IndexTest-retest (part II)

ValidityRasch analysisConfirmatory factor analysisConcurrent validityKnow group validity

J. Brodersen, H. Thorsen, and S. Kreiner. Validation of a condition-specific measure for women having an abnormal screening mammography. Value in Health 10 (4):294-304, 2007.

Psychosocial consequences of false-positive screening results - breast cancer as an example 15

COS-BC part I

Psychosocial consequences of false positive screening results

Anxiety – 6 items

Behavioural aspects - 7 items

Sense of dejection – 6 items

Sleep problems - 4 items

Breast examination - 2 items

Sexuality - 2 items

Single items – 3 items

J. Brodersen, H. Thorsen, and S. Kreiner. Validation of a condition-specific measure for women having an abnormal screening mammography. Value in Health 10 (4):294-304, 2007.

Psychosocial consequences of false-positive screening results - breast cancer as an example 16

COS-BC part II

Psychosocial consequences of false positive screening results

Anxious about/belief in (not) having breast cancer – 2 itemsMore or less relax - 2 itemsSocial relationship – 3 itemsExistential values - 6 items

J. Brodersen. Measuring psychosocial consequences of false-positive screening results - breast cancer as an example, Department of General Practice, Institute of Public Health, Faculty of Health Sciences, University of Copenhagen:Månedsskrift for Praktisk Lægegerning, Copenhagen. ISBN: 87-88638-36-7, 2006.

Psychosocial consequences of false-positive screening results - breast cancer as an example 17

Scores of anxiety (0-18)

Group Mean score

Abnormal screening 6.39

Breast cancer 7.38

False-positive 3.04

Undiagnosed 4.38

Normal screening 0.97

J. Brodersen, H. Thorsen, and S. Kreiner. Validation of a condition-specific measure for women having an abnormal screening mammography. Value in Health 10 (4):294-304, 2007.

Psychosocial consequences of false-positive screening results - breast cancer as an example 18

5 response category

After the examinations I have thought about the broader aspects of life:

Much less Less The same as

before More Much

more

Fewer thoughts about

life

More thoughts about life

Psychosocial consequences of false-positive screening results - breast cancer as an example 19

Know group validity - 1

Breast cancer - anxiety/mistrust

0%

20%

40%

60%

80%

100%

muchgreater

greater same asbefore

less muchless

Response categories

Normal

False positive

Psychosocial consequences of false-positive screening results - breast cancer as an example 20

Know group validity - 2

Feeling relaxed and calm

0%

20%

40%

60%

80%

100%

muchless

less same asbefore

greater muchgreater

Response categories

Normal

False positive

Psychosocial consequences of false-positive screening results - breast cancer as an example 21

Know group validity - 3

Relation to social network

0%

20%

40%

60%

80%

100%

much less less same asbefore

greater muchgreater

Response categories

Normal

False positive

Psychosocial consequences of false-positive screening results - breast cancer as an example 22

Know group validity - 4

Existential values

0%

20%

40%

60%

80%

100%

muchless

less same asbefore

greater muchgreater

Response categories

Normal

False positive

Psychosocial consequences of false-positive screening results - breast cancer as an example 23

Know group validity - 4

Existential values

0%

20%

40%

60%

80%

100%

muchless

less same asbefore

greater muchgreater

Response categories

Normal

False positive

Psychosocial consequences of false-positive screening results - breast cancer as an example 24

Content of presentation

Medical screening Breast cancer screening Psychosocial consequences Conclusions and perspectives

Psychosocial consequences of false-positive screening results - breast cancer as an example 25

Conclusion 1

The conclusions drawn from previously conducted studies regarding long-term psychosocial consequences of false-positive screening mammography should remain tentative

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Conclusion 2a

A valid and reliable condition-specific instrument measuring psychosocial consequences of abnormal and false-positive screening mammography has been established

Psychosocial consequences of false-positive screening results - breast cancer as an example 27

Conclusion 2b

Consequences of Screening on Breast Cancer (COS-BC)1.Psychosocial consequences of

abnormal and false-positive screening mammography

2.Long-term psychosocial consequences of false-positive screening mammography

Psychosocial consequences of false-positive screening results - breast cancer as an example 28

Conclusion 3

There are substantial negative psychosocial consequences associated with having an abnormal screening mammography later confirmed to be false-positive

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Implications for practice

Letters and folders posted at invitation to screening should contain information on the negative psychosocial consequences arising from abnormal and false-positive screening results

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Implications for research

Need for valid instruments in the area of psychosocial consequences of screening for any cancers

To establish core-items and core-subscales relevant for any kind of cancer screening

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Consequences Of Screening

Lung cancer P1: 17 items P2: 4 items

Cervical cancer P1: 40 items

Breast cancer P1: 4 items

Core P1: 26 itemsP2: 22 items