False positive screening test results in the National Health Service Breast Cancer Screening Programme: minimising harms and seeking benefits

Abstract

Population-based screening for breast cancer produces unintended harms for women who are screened. In England, approximately 65,000 women receive a false positive screening test result each year under the National Health Service Breast Screening Programme. A false positive screening test result occurs when an initial screening mammogram indicates an abnormality that requires further investigations, which ultimately indicate that cancer is not present. These results are associated with long-lasting adverse emotional outcomes for women. However, the strength of evidence is limited by several factors: the predominance of observational study designs, inconsistent effects related to specific emotion outcomes, a lack of systematic synthesis of the relevant qualitative evidence, and a scarcity of recent research with women and breast screening healthcare professionals in the UK. Our understanding of the nature of emotional impact from false positive screening test results is therefore limited. The present thesis aimed to better understand the emotional impact of false positive screening test results on women in the National Health Service Breast Screening Programme. Three studies were conducted. The first, a systematic review of qualitative research, investigated women's experiences and views about receiving a false positive breast screening test result (Chapter 3). The review findings indicated that most women experienced elevated anxiety and worry about breast cancer during the diagnostic period. The eventual negative result typically brought significant relief to them. However, some women continued to experience lasting worry, potentially related to inadequate communication of their result. During this review, the Critical Appraisal Skills Programme tool for appraising the quality of included studies was modified to optimise its contribution to the review. The process is reported in detail in Chapter 4. Informed by the review findings, the second study utilised qualitative interview methods to investigate breast screening healthcare professionals' experiences of caring for women recalled in screening (Chapter 5). The findings indicated that managing women's elevated anxiety is central to their clinical role. This brought additional challenges alongside competing clinical pressures. They described specific communication practices intended to manage women's emotions and facilitate their understanding of the recall process. To address the discrepancy between systematic reviews of quantitative and qualitative findings, a systematic review of quantitative research was conducted to investigate the reporting clarity and rationale for outcomes and outcome measures used to assess the emotional impact of false positive breast screening test results (Chapter 6). The review found noteworthy heterogeneity in outcomes assessed and outcome measures used and a lack of clear rationale for these. This highlighted a gap in our conceptual understanding of the emotional impact of false positive screening test results. To reduce the emotional harm of false positive breast screening test results, it is worth assessing the acceptability and feasibility of altering current screening programme practices. These include the distribution of screening information, including clinical nurse specialist support earlier in the screening pathway, and developing evidence-based guidance to support screening healthcare professionals to communicate these results. The cancer screening field would benefit from an agreed consensus on and standardised measurement approach to investigate emotional harms across the spectrum of screening test results.

Date of Award	1 Aug 2024
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Michelle Harvie (Supervisor), Joanna Brooks (Supervisor) & David French (Supervisor)