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I enjoyed the excellent report by Welch and Fisher (1), describing the screening and subsequent diagnostic experience of women in the Medicare population. These authors report a screening-incurred work-up rate of 8.5% and positive predictive values of 0.08– 0.14 in women more than 65 years of age. They conclude that the general practice of mammography in the United States may involve lower thresholds (and higher rates) for subsequent testing than have been expected or previously reported. My own interpretation of their data was somewhat different. Published guidelines for the practice of screening mammography in this country state the expectations for quality mammography practice, including an incurred work-up rate of less than 10% and positive predictive values of 0.05–0.10 (2,3). One would expect, because of the higher prevalence of cancer in older women, that the biopsy rates and positive predictive values in older women would be greater than in younger women. Moreover, there is evidence that reducing the incurred work-up rate substantially below 8%–10% reduces the sensitivity of mammography and the number of cancers detected per 1000 women screened (4). To analyze rates of incurred workup and positive predictive values without including related outcome data is looking at only a small part of the picture.

Re: Diagnostic Testing Following Screening Mammography in the Elderly