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Timely follow-up for positive cancer screening results remains suboptimal, and the evidence base to inform decisions on optimizing the timeliness of diagnostic testing is unclear. This systematic review evaluated published studies regarding time to follow-up after a positive screening for breast, cervical, colorectal, and lung cancers. The quality of available evidence was very low or low across cancers, with potential attenuated or reversed associations from confounding by indication in most studies. Overall, evidence suggested that the risk for poorer cancer outcomes rises with longer wait times that vary within and across cancer types, which supports performing diagnostic testing as soon as feasible after the positive result, but evidence for specific time targets is limited. Within these limitations, we provide our opinion on cancer-specific recommendations for times to follow-up and how existing guidelines relate to the current evidence. Thresholds set should consider patient worry, potential for loss to follow-up with prolonged wait times, and available resources. Research is needed to better guide the timeliness of diagnostic follow-up, including considerations for patient preferences and existing barriers, while addressing methodological weaknesses. Research is also needed to identify effective interventions for reducing wait times for diagnostic testing, particularly in underserved or low-resource settings. CA Cancer J Clin 2018;68:199-216. © 2018 American Cancer Society.

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Performance incentives for preventive care may encourage inappropriate testing, such as cancer screening for patients with short life expectancies. Defining screening colonoscopies for patients with a >50% 4-year mortality risk as inappropriate, the authors performed a pre-post analysis assessing the effect of introducing a cancer screening incentive on the proportion of screening colonoscopy orders that were inappropriate. Among 2078 orders placed by 23 attending physicians in 4 academic general internal medicine practices, only 0.6% (n = 6/1057) of screening colonoscopy orders in the preintervention period and 0.6% (n = 6/1021) of screening colonoscopy orders in the postintervention period were deemed "inappropriate." This study found no evidence that the incentive led to an increase in inappropriate screening colonoscopy orders.

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BACKGROUND: Mammography screening reduces breast cancer mortality, but false-positive tests are common. Few studies have assessed racial differences in false-positive rates. OBJECTIVES: We compared false-positive mammography rates for black and white women, and the effect of patient and facility characteristics on false positives. RESEARCH DESIGN AND SUBJECTS: A prospective cohort study. From a sample of the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), we identified black/African American (N=3176) or white (N=26,446) women with no prior breast surgery or breast cancer. MEASURES: Race, demographics, and breast cancer risk factors were self-reported. Results of initial digital and film mammograms were assessed. False positives were defined as a positive mammogram (Breast Imaging Reporting and Data System category 0, 4, 5) with no cancer diagnosis within 15 months. RESULTS: The false-positive rate for digital mammograms was 9.2% for black women compared with 7.8% for white women (P=0.009). After adjusting for age, black women had 17% increased odds of false-positive digital mammogram compared with whites (OR=1.17; 95% CI, 1.01-1.35; P=0.033). This association was attenuated after adjusting for patient factors, prior films, and study site (OR=1.04; 95% CI, 0.91-1.20; P=0.561). There was no difference in the occurrence of false positives by race for film mammography. CONCLUSIONS: Black women had higher frequency of false-positive digital mammograms explained by lack of prior films and study site.The variation in the disparity between the established technique (film) and the new technology (digital) raises the possibility that racial differences in screening quality may be greatest for new technologies.

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Breast cancer is the main cause of cancer deaths for Hispanic women. This study analyzes the role of functional health literacy on mammography screening behavior and adherence of Hispanic women. Survey data from 722 Mexican American women age 40 and over residing in the Lower Rio Grande Valley of Texas in 2008 were used to estimate logistic regression models to assess the role of functional health literacy on mammography screening behavior and adherence. About 51% of survey respondents had a functional health literacy level deemed as inadequate or marginally functional. After adjusting for other factors, women with adequate health literacy levels were more likely to report to have ever had a mammogram (odds ratio [OR] = 2.92; 95% confidence interval [CI] = 1.62-5.28), to have had a mammogram within the last 2 years (OR = 1.70; 95% CI = 1.14-2.53) or to have had one within the last year (OR = 2.30; 95% CI = 1.54-3.43), compared to women with inadequate or marginally adequate functional health literacy levels. Inadequate/marginal functional health literacy is strongly associated with lower mammography screening. Large improvements in breast cancer control in this population may come from either basic advances in health literacy or by tailored approaches to help women with low literacy navigate local health care systems.

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