CHICAGO—Efforts to improve mammography screening in the United States (U.S.) should target lowering the recall rate (further evaluation and testing after mammography) without reducing the cancer detection rate, according to a study in the October 22/29 issue of The Journal of the American Medical Association (JAMA).

According to background information in the article, mammographic screening in the U.S. is provided in diverse settings, such as private practice, health maintenance organizations, and academic medical centers. In the United Kingdom (U.K.), a single organized screening program run by the National Health Service provides virtually all mammographic screening for women aged 50 years or older.

Rebecca Smith-Bindman, M.D., from the University of California-San Francisco, and colleagues compared screening mammography performance, including recall (the percentage of mammograms in which there is a recommendation for prompt additional testing, clinical evaluation, or percutaneous [through the skin] biopsy), surgical biopsy, and cancer detection rates for screening mammography among similarly aged women between the U.S. and the U.K.

Women aged 50 years or older were identified who underwent 5.5 million mammograms from January 1, 1996 to December 31, 1999, within three large-scale mammography programs: the Breast Cancer Surveillance Consortium (BCSC, n = 978,591); the National Breast and Cervical Cancer Early Detection Program (NBCCEDP, n= 613,388) in the United States; and the National Health Service Breast Screening Program (NHSBSP, n=3.94 million) in the United Kingdom. A total of 27,612 women were diagnosed with breast cancer within 12 months of screening among the three groups.

"Recall rates were approximately twice as high in the United States than in the United Kingdom for all age groups; however, cancer rates were similar," the authors report. "Among women aged 50 to 54 years who underwent a first screening mammogram, 14.4 percent in the BCSC and 12.5 percent in the NBCCEDP were recalled for further evaluation vs. only 7.6 percent in the NHSBSP. Cancer detection rates per 1,000 mammogram screens were 5.8, 5.9, and 6.3, in the BCSC, NBCCEDP, and NHSBSP, respectively," the authors found. "A similar percentage of women underwent biopsy in each setting, but rates of percutaneous biopsy were lower and open surgical biopsy was higher in the U.S. ... Most of the difference in the open surgical biopsy rates was attributed to procedures among women who did not have breast cancer, with negative open surgical biopsy rates two to three times as high in the United States vs. the United Kingdom," the authors write.

"The goal of any cancer screening effort is to obtain high cancer detection rates while avoiding unnecessary diagnostic evaluation following false-positive results, which are costly and associated with ongoing psychological morbidity," the authors state.

"In the United Kingdom, the NHSBSP has set and reached targets that emphasize high rates of cancer detection and low recall. Recall rates in the United Kingdom are now substantially lower than in the United States with no substantial reduction in cancer detection. We believe this success stems primarily from a centralized program of continuous quality improvement," the authors comment.

CHICAGO—Young adults who are impatient or have hostile attitudes are at higher risk of developing hypertension when they get older, according to an article in the October 22/29 issue of The Journal of the American Medical Association (JAMA).

According to background information in the article, individual psychosocial factors, such as the type A behavior pattern (time urgency/impatience [TUI], achievement striving/competitiveness [ASC], hostility), depression, and anxiety, have been linked with hypertension, though study results have been inconsistent. According to the National Health Examination and Nutrition Survey III (1988-1994), an estimated 43 million U.S. adults aged 18 years or older are hypertensive (systolic blood pressure equal or greater than 140 mm Hg, diastolic blood pressure equal or greater than 90 mm Hg, or taking antihypertensive medication). High blood pressure has long been established as a significant risk factor for cardiovascular disease (CVD).

Lijing L. Yan, Ph.D., M.P.H., of the Feinberg School of Medicine, Northwestern University, Chicago, and colleagues investigated the relationships of the three main components of the type A behavior pattern - hostile attitudes (hostility), TUI, and ASC; and two other major psychosocial factors, depression and anxiety, with long-term risk of developing hypertension. The researchers used data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, which included 3,308 black and white adults aged 18 to 30 years (in 1985 and 1986) from 4 U.S. metropolitan areas and followed-up through 2000 to 2001, with assessments taken for psychosocial factors and high blood pressure.

"In this cohort of white and black young adults, we found that TUI and hostility assessed during young adulthood were associated in a dose-response manner with a higher risk of developing hypertension 15 years later. These associations were independent of age, sex, race, baseline systolic blood pressure, education, body mass index, daily alcohol consumption, and level of physical activity," the authors write. "With the exception of white men, no consistent relationship was observed between ASC and 15-year risk of hypertension and between depression or anxiety and 10-year risk of hypertension."

CHICAGO—Patients who have their common bile duct injured during removal of their gallbladder have nearly three times the risk of death in the next few years compared with patients who don't incur the injury, according to an article in the October 22/29 issue of The Journal of the American Medical Association (JAMA).

Removal of the gallbladder (cholecystectomy) is the most commonly performed elective abdominal surgical procedure in the United States, with about 750,000 performed each year, according to background information in the article. Common bile duct (CBD) injury occurs in 1 of 200 cholecystectomies, is an important source of patient illness after gallbladder surgery, and is the leading source for medical malpractice claims against general surgeons. Repair of a damaged CBD is a technically challenging undertaking that may best be performed by surgeons experienced at operating on the bile duct. The impact of injury to the CBD on survival has been unclear.

David R. Flum, M.D., M.P.H., of the University of Washington, Seattle, and colleagues examined the impact of CBD injury among Medicare beneficiaries who had undergone cholecystectomy. The researchers used data from the Medicare National Claims History Part B (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury.

The researchers found that of the 1,570,361 patients identified as having had a cholecystectomy, 7,911 patients (0.5 percent) had CBD injuries. Thirty-three percent of all patients died within the 9.2-year follow-up period; 55.2 percent of patients without CBD injury were alive compared with only 19.5 percent of patients who had a CBD injury. Most of the impact of CBD injury appeared in the first two years after cholecystectomy.

"[Patients with CBD injury] were nearly 3 times more likely to die within 10 years after cholecystectomy than noninjured patients, even after controlling for age and comorbid illnesses. We also found that improved survival was more likely when a different, more experienced surgeon performed the CBD repair, but that 75 percent of repair procedures were in fact performed by the same surgeon associated with the injury," the authors write. Patients had a 11 percent increased risk of death if the repairing surgeon was the same as the injuring surgeon.

SPECIFIC PSYCHOSOCIAL FACTORS MAY LEAD TO LONG-TERM RISK OF HIGH BLOOD PRESSURE IN YOUNG ADULTS