Detection of Contralateral Breast Cancer Using Diffusion-Weighted Magnetic Resonance Imaging in Women with Newly Diagnosed Breast Cancer: Comparison with Combined Mammography and Whole-Breast Ultrasound

ObjectiveTo compare the screening performance of diffusion-weighted (DW) MRI and combined mammography and ultrasound (US) in detecting clinically occult contralateral breast cancer in women with newly diagnosed breast cancer.Materials and MethodsBetween January 2017 and July 2018, 1148 women (mean age ± standard deviation, 53.2 ± 10.8 years) with unilateral breast cancer and no clinical abnormalities in the contralateral breast underwent 3T MRI, digital mammography, and radiologist-performed whole-breast US. In this retrospective study, three radiologists independently and blindly reviewed all DW MR images (b = 1000 s/mm² and apparent diffusion coefficient map) of the contralateral breast and assigned a Breast Imaging Reporting and Data System category. For combined mammography and US evaluation, prospectively assessed results were used. Using histopathology or 1-year follow-up as the reference standard, cancer detection rate and the patient percentage with cancers detected among all women recommended for tissue diagnosis (positive predictive value; PPV₂) were compared.ResultsOf the 30 cases of clinically occult contralateral cancers (13 invasive and 17 ductal carcinoma in situ [DCIS]), DW MRI detected 23 (76.7%) cases (11 invasive and 12 DCIS), whereas combined mammography and US detected 12 (40.0%, five invasive and seven DCIS) cases. All cancers detected by combined mammography and US, except two DCIS cases, were detected by DW MRI. The cancer detection rate of DW MRI (2.0%; 95% confidence interval [CI]: 1.3%, 3.0%) was higher than that of combined mammography and US (1.0%; 95% CI: 0.5%, 1.8%; p = 0.009). DW MRI showed higher PPV₂ (42.1%; 95% CI: 26.3%, 59.2%) than combined mammography and US (18.5%; 95% CI: 9.9%, 30.0%; p = 0.001).ConclusionIn women with newly diagnosed breast cancer, DW MRI detected significantly more contralateral breast cancers with fewer biopsy recommendations than combined mammography and US.     

Survival Rates of Breast Cancer Patients Aged 40 to 49 Years according to Detection Modality in Korea: Screening Ultrasound versus Mammography

ObjectiveThe aim of this study was to compare the survival rates of Korean females aged 40 to 49 years with breast cancer detected by supplemental screening ultrasound (US) or screening mammography alone.Materials and MethodsThis single-institution retrospective study included 240 patients with breast cancer (mean age, 45.1 ± 2.8 years) detected by US or mammography who had undergone breast surgery between 2003 and 2008. Medical records were reviewed for clinicopathologic characteristics and detection methods. Disease-free survival (DFS) and overall survival (OS) were compared between patients with breast cancer in the US and mammography groups using the log-rank test. Multivariable cox regression analysis was used to identify independent variables associated with DFS and OS.ResultsAmong the 240 cases of breast cancer, 43 were detected by supplemental screening US and 197 by screening mammography (mean follow-up: 7.4 years, 93.3% with dense breasts). There were 19 recurrences and 16 deaths, all occurring in the mammography group. While the US group did not differ from the mammography group in tumor stage, the patients in this group were more likely to undergo breast-conserving surgery and radiation therapy than the mammography group. The US group also showed better DFS (p = 0.016); however, OS did not differ between the two groups (p = 0.058). In the multivariable analysis, the US group showed a lower risk of recurrence (hazard ratio, 0.097; 95% confidence interval, 0.001–0.705) compared to the mammography group.ConclusionOur study found that Korean females aged 40–49 years with US-detected breast cancer showed better DFS than those with mammography-detected breast cancer. However, there were no statistically significant differences in OS.     

Utilization and Cancer Yield of Probably Benign Assessment Category in the National Mammography Database: 2009 to 2018

PurposeData on utilization rate and cancer yield of BI-RADS® category 3 in routine clinical practice in diagnostic mammography are sparse. The aim of this study was to determine utilization rate and cancer yield of BI-RADS 3 in diagnostic mammography in the ACR National Mammography Database (NMD).MethodsRetrospective analysis of NMD mammograms from January 1, 2009, to June 30, 2018, was performed. BI-RADS 3 utilization rate in diagnostic setting was calculated and stratified by patient, facility, and examination-level variables. Patient-level cancer yield was calculated among women with BI-RADS 3 assessment and adequate follow-up (imaging follow-up ≥24 months or biopsy). Logistic regression was performed to assess the odds of utilization of BI-RADS 3, with respect to facility, examination, and patient variables, and the odds of malignancy among patients with probably benign findings. Chi-square and t tests were used to determine significance (P < .05).ResultsData from 19,443,866 mammograms from 500 NMD facilities across 31 states were analyzed, of which 3,039,952 were diagnostic mammograms. Utilization rate of BI-RADS 3 was 15.5% (470,155 of 3,039,952) in the diagnostic setting. There was a statistically significant difference in BI-RADS 3 utilization rate across all collected variables (P < .001). Patient-level cancer yield at 2-year follow-up was 0.91% (2,009 of 220,672; 95% confidence interval [CI], 0.87%-0.95%) in the diagnostic setting. Patient and examination variables associated with significantly higher likelihood of malignancy included calcifications (odds ratio, 4.27; 95% CI, 2.43-7.51), patient age > 70 years (odds ratio, 3.77; 95% CI, 2.49-5.7), and presence of prior comparisons (odds ratio, 1.23; 95% CI, 1.07-1.42).ConclusionsIn the NMD, BI-RADS 3 assessment was common in diagnostic mammography (15.5%), with an overall cancer yield of 0.91%, less than the benchmark of 2%. Utilization trends in diagnostic mammography warrant further research for optimization of use.     

Comparison of screening CEDM and MRI for women at increased risk for breast cancer: A pilot study

ObjectivesContrast enhanced digital mammography (CEDM) is a new breast imaging technology increasingly used in the diagnostic setting but its utility in the pure screening setting has not been reported. The goal of this pilot study is to prospectively compare screening CEDM to breast MRI in women with an increased risk for breast cancer.MethodsIn this IRB-approved HIPAA-compliant study, 318 women at increased breast cancer risk were consented (December 2012–May 2015) to undergo CEDM in addition to their scheduled MRI. CEDM was performed within 30 days of screening MRI. CEDM was interpreted blinded to MRI. The reference standard was defined as a combination of pathology and 2-year imaging follow-up.ResultsData from 307/318 patients were evaluable. Three cancers (two invasive cancers, one ductal carcinoma in situ) were detected at first round screening: MRI detected all three and CEDM detected the two invasive cancers. None of the three cancers was seen on the low energy mammograms which are comparable to conventional mammography. At 2 year imaging follow up, there were 5 additional screen detected cancers and no palpable cancers. The positive predictive value 3 (PPV₃) for CEDM was 15% (2/13, 95% CI: 2–45%) and 14% for MRI (3/21, 95% CI: 3–36%). The specificity of CEDM and MRI were 94.7% and 94.1% respectively.ConclusionsBoth CEDM and MRI detected additional cancers not seen on conventional mammography, primarily invasive cancers. Our pilot data suggest that CEDM could be valuable as a supplemental imaging exam for women at increased risk for breast cancer who do not meet the criteria for MRI or for whom access to MRI is limited. Validation in larger multi institutional trials is warranted.     

Comparing Diagnostic Performance of Digital Breast Tomosynthesis and Full-Field Digital Mammography

ObjectiveCompare diagnostic performance of screening full-field digital mammography (FFDM), a hybrid FFDM and digital breast tomosynthesis (DBT) environment, and DBT only.Materials and MethodsThis institutional review board–approved, retrospective study consisted of all patients undergoing screening mammography at an urban academic medical center and outpatient imaging facility between January 1, 2011, and December 31, 2017. We used the electronic health record data warehouse to extract report data and patient demographics. A validated natural language processing algorithm extracted BI-RADS score from each report. An institutional cancer registry identified cancer diagnoses. Primary outcomes of recall rate, cancer detection rate (CDR), and positive predictive value 1 (PPV1) were calculated for three periods: FFDM-only environment, hybrid environment, and DBT-only environment. A χ² test was used to compare recall rate, CDR, and PPV1.ResultsA total of 179,028 screening mammograms comprised the study cohort: 41,818 (23.3%) during the FFDM-only period, 83,125 (46.4%) during the hybrid period, and 54,084 (30.2%) during the DBT-only period. Recall rates were 10.4% (4,279 of 41,280) for the FFDM-only period, 10.6% (8,761 of 82,917) for the hybrid period, and 10.8% (5,850 of 54,020) for the DBT-only period (P = .96). CDR (cancers per 1,000 examinations) was 2.6 per 1,000, 4.9 per 1,000, and 6.0 per 1,000 for FFDM only, hybrid, and DBT only, respectively (P < .01). PPV1s (number of cancers per number of recalls) were 2.5% for the FFDM-only period, 4.6% for the hybrid period, and 5.6% for the DBT-only period (P < .01).ConclusionRecall rates were not significantly different within the three periods in the breast imaging practice. However, PPV1 and CDR were significantly higher with DBT only.     

Outcomes by Race in Breast Cancer Screening With Digital Breast Tomosynthesis Versus Digital Mammography

PurposeDigital breast tomosynthesis (DBT) in conjunction with digital mammography (DM) is becoming the preferred imaging modality for breast cancer screening compared with DM alone, on the basis of improved recall rates (RR) and cancer detection rates (CDRs). The aim of this study was to investigate racial differences in the utilization and performance of screening modality.MethodsRetrospective data from 63 US breast imaging facilities from 2015 to 2019 were reviewed. Screening outcomes were linked to cancer registries. RR, CDR per 1,000 examinations, and positive predictive value for recall (cancers/recalled patients) were compared.ResultsA total of 385,503 women contributed 542,945 DBT and 261,359 DM screens. A lower proportion of screenings for Black women were performed using DBT plus DM (referred to as DBT) (44% for Black, 48% for other, 63% for Asian, and 61% for White). Non-White women were less likely to undergo more than one mammographic examination. RRs were lower for DBT among all women (8.74 versus 10.06, P < .05) and lower across all races and within age categories. RRs were significantly higher for women with only one mammogram. CDRs were similar or higher in women undergoing DBT compared with DM, overall (4.73 versus 4.60, adjusted P = .0005) and by age and race. Positive predictive value for recall was greater for DBT overall (5.29 versus 4.45, adjusted P < .0001) and by age, race, and screening frequency.ConclusionsAll racial groups had improved outcomes with DBT screening, but disparities were observed in DBT utilization. These data suggest that reducing inequities in DBT utilization may improve the effectiveness of breast cancer screening.     

Breast compression and reported pain during mammographic screening

IntroductionWe aimed to investigate the association between breast compression and experienced pain during mammographic screening.MethodsUsing a questionnaire, we collected information on pain experienced during mammography from 1155 women screened in Akershus, February–March 2018, as a part of BreastScreen Norway. The questionnaire provided information on pain using a numeric rating scale (NRS, 0–10) and related factors. Data on compression force (Newton, N), pressure (kilopascal, kPa) and breast characteristics were extracted from the DICOM-header and a breast density software. Log-binomial regression was used to determine the relative risk (RR) of severe versus mild/moderate experienced pain associated with compression parameters, adjusting for breast characteristics and related factors.ResultsMean score of experienced pain was 2.2, whereas 6% of the women reported severe pain (≥7) during the examination. High body mass index (BMI) (≥27.3 kg/m²) was associated with a higher RR of pain scores ≥7 (RR 1.86, 95%CI 1.02–3.36) compared to medium BMI (23.7–27.2 kg/m²). Low compression pressure (4.0–10.2 kPa) was associated with a higher RR of severe pain (RR 2.93, 95%CI 1.39–6.20), compared with medium compression pressure (10.3–13.5 kPa) after adjusting for contact area, age, compressed breast thickness, volumetric breast density and BMI. The risk of severe versus mild/moderate pain (≥7 versus <7) decreased by 2% with increasing compression force (RR 0.98, 95%CI 0.97–1.00).ConclusionWomen reported low levels of pain during mammography. Further knowledge about factors affecting experienced pain is needed to personalize the examination to the individual woman.Implications for practicePain in shoulder(s) and/or neck prior to screening should be considered by the radiographers in a practical screening setting. A compression force of 100–140 N and pressure of 10.3–13.5 kPa are acceptable with respect to reported pain during mammography.     

Mammography screening for breast cancer: Four years of nationwide screening in Finland

Biennial breast cancer screening with two-view screen-film mammography started on a nationwide basis in Finland in January 1987. Women have been invited by birth year cohort to attend a free-of-charge examination. The program has progressively expanded to include two or three new birth year cohorts yearly of women between 50 and 59 years of age. Participation has averaged 89% and the breast cancer detection rate has ranged from 3.8 to 3.3 per thousand compared with an expected annual incidence of breast cancer in this age group of 1.6 per thousand. The positive predictive value has increased from 33% to 53%. Results to date, collected by the radiologists responsible for each screening centre, indicate an acceptable sensitivity and specificity for the program. Specificity is much better than that which had generally been considered possible or practical. Double reading of all films, intensive training in both mammography and mammography screening, and careful evaluation of ongoing results by the radiologists involved are all believed to be important factors leading to a high sensitivity and specificity of mammography screening. Correspondence to: M. Pamilo     

Screening for breast cancer with mammography

Mammography is generally accepted as a useful problem-solving clinical tool in characterizing known breast lesions, so that appropriate and timely treatment can be given. However, it remains grossly underutilized at what it does best: screening. The major strengths of mammography are a) its ability to detect breast cancer at a smaller, potentially more curable stage than any other examination, and b) its proved efficacy in reducing breast cancer mortality in asymptomatic women aged 40–74. If, as has recently been estimated, screening with mammography and physical examination can be expected to lower breast cancer deaths by 40%–50% among those actually examined (13), then the lives of almost 20,000 U.S. women might be saved each year if screening were to become very widely used. The challenges of the next decade are clear, to mount much more effective campaigns to educate physicians and lay women about the life-saving benefits of breast cancer screening, to devise increasingly effective and lower cost screening strategies, to further improve the current high quality of mammographic imaging despite its increasing proliferation, and to train large numbers of breast imaging specialists to guarantee that the growing case load of screening and problem-solving mammograms is interpreted with a very high level of skill.     

Performance of Screening Mammography: A Report of the Alliance for Breast Cancer Screening in Korea

ObjectiveTo analyze the diagnostic accuracy and trend in screening mammography in Korea.ResultsWe enrolled 128756 cases from 10 hospitals from 2005 to 2010. The recall rate was 19.1% with a downward trend over time (-12.1% per year; 95% CI, -15.9 to -8.2). The CDR was 2.69 per 1000 examinations, without a significant trend. The PPV was 1.4% with an upward trend (20.8% per year; 95% CI, 15.2 to 26.7). The sensitivity was 86.5% without a significant trend, whereas the specificity was 81.1% with an upward trend (3.3% per year; 95% CI, 2.1 to 4.5). The FPR was 18.9% with a downward trend (-12.4% per year; 95% CI, -16.2 to -8.4). The ICR was 0.5 per 1000 negative examinations without a significant trend. There were institutional variations in the diagnostic accuracy and trend except for the CDR, sensitivity, and ICR.ConclusionThe sensitivity and CDR of screening mammography in the ABCS-K from 2005 to 2010 were compatible with those for Western women. The recall rate, PPV and specificity, however, were suboptimal, although they showed significant improvements over this period. A further analysis is required to explain institutional variations.     

Sensitivity and specificity of first screen mammography in the Canadian National Breast Screening Study: a preliminary report from five centers

Sensitivity and specificity of first screen mammography in a randomized screening trial at five centers are reported. A total of 23,101 women underwent mammography; in 139, breast cancer was detected at first screening; in 20, less than 12 months after first screening; and in 47, at second screening. All 206 cancer cases were histologically confirmed, and 174 were defined as being detectable at first screening. Average length of follow-up for all women was 3.2 years. Interpretations of first screen mammograms by the center radiologists were matched to known outcomes. Simultaneous blind review was performed by a single reference radiologist with mammograms from all 206 cancer cases and those of a random sample of 739 women not known to have breast cancer at 15 months or more after initial screening. Overall, the five screening centers achieved a sensitivity of 69% (range, 60%-78%), a specificity of 94% (range, 93%-96%), a positive predictive value of 8.6% (range, 3%-16%), and a negative predictive value of 99.7% (range, 99.6%-99.9%).     

Clinical Image Quality in Daily Practice of Breast Cancer Mammography Screening

Objective

To assess the quality of screening mammograms performed in daily practice in the Quebec Breast Cancer Screening Program.

Subjects and Methods

Clinical image quality of a random subsample of 197 screening mammograms performed in 2004-2005 was independently evaluated by 2 radiologists based on the criteria by Canadian Association of Radiologists (CAR). When disagreement occurred for overall judgement or positioning score, the mammograms were reviewed by a third radiologist. Cohen's kappas for interrater agreement were computed. Multivariable robust Poisson regression models were used to study associations of overall quality and positioning with body mass index (BMI) and breast density.

Results

The CAR criteria were not satisfied for 49.7% of the mammograms. Positioning was the quality attribute most often deficient, with 37.2% of mammograms failing positioning. Interrater agreement ranged from slight (kappa = 0.02 for compression and sharpness) to fair (kappa = 0.30 for exposure). For overall quality, women with a BMI ≥ 30 kg/m² had a failure proportion of 67.5% compared with 34.9% for women with a BMI<25 kg/m² (risk ratio 2.1 [95% confidence interval, 1.5-3.0]). For positioning, women with a BMI ≥ 30 kg/m² had a failure proportion of 53.8% compared with 27.9% for women with a BMI < 25 kg/m² (risk ratio 1.9 [95% confidence interval, 1.2-3.1]). Effects of breast density on image quality differed among radiologists.

Conclusion

Despite measures to ensure high-quality imaging, including CAR accreditation, approximately half of this random sample of screening mammograms failed the CAR quality standards. It would be important to define quality targets for screening mammograms carried out in daily practice to interpret such observations.     

Primary Care Providers Underutilize Breast Screening MRI for High-Risk Women

ObjectiveSupplemental MRI screening for women at high risk for breast cancer is underutilized. Our study assessed how primary care providers in our healthcare network identify high-risk women and recommend high-risk screening breast MRI.MethodsAn electronic survey was distributed to providers in OB/GYN, family, and internal medicine departments between 1/14/19 and 3/22/19. The survey inquired about methods used to assess breast cancer risk, familiarity with the American Cancer Society's definition of high-risk, and whether screening breast MRI is recommended for high-risk women.ResultsResponse rate was 17% (89/524). After excluding providers who ordered ≤10 mammograms per year, the study included 75 respondents, who mostly ordered 10-1000 mammograms per year and supported annual/biennial screening mammogram starting at age 40-50 years. More providers reported estimating breast cancer risk qualitatively (with family, clinical history, and/or breast density) than quantitatively with risk calculators (73/75, 97% vs 22/75, 29%). A minority of providers (23/75, 31%) correctly defined high lifetime risk. Only 9/75 (12%) providers recommended screening MRI for high-risk women. Use of quantitative risk calculators or ability to correctly define high-risk were not associated with likelihood of recommending MRI screening. More providers had recommended MRI for screening in the setting of dense breasts than for high-risk screening (23/75, 31% vs 9/75, 12%).ConclusionPrimary care providers at our institution did not routinely recommend screening MRI for high-risk women. Risk assessment and reporting at the time of mammography may improve MRI utilization and is an opportunity for radiologists to add value and directly participate in patient-centered care.     

Facility Variability in Examination Indication Among Women With Prior Breast Cancer: Implications and the Need for Standardization

ObjectiveWe sought to identify and characterize examinations in women with a personal history of breast cancer likely performed for asymptomatic surveillance.MethodsWe included surveillance mammograms (1997-2017) in asymptomatic women with a personal history of breast cancer diagnosed at age ≥18 years (1996-2016) from 103 Breast Cancer Surveillance Consortium facilities. We examined facility-level variability in examination indication. We modeled the relative risk (RR) and 95% confidence intervals (CIs) at the examination level of a (1) nonscreening indication and (2) surveillance interval ≤9 months using Poisson regression with fixed effects for facility, stage, diagnosis age, surgery, examination year, and time since diagnosis.ResultsAmong 244,855 surveillance mammograms, 69.5% were coded with a screening indication, 12.7% short-interval follow-up, and 15.3% as evaluation of a breast problem. Within a facility, the proportion of examinations with a screening indication ranged from 6% to 100% (median 86%, interquartile range 79%-92%). Facilities varied the most for examinations in the first 5 years after diagnosis, with 39.4% of surveillance mammograms having a nonscreening indication. Within a facility, breast conserving surgery compared with mastectomy (RR = 1.64; 95% CI = 1.60-1.68) and less time since diagnosis (1 year versus 5 years; RR = 1.69; 95% CI = 1.66-1.72; 3 years versus 5 years = 1.20; 95% CI = 1.18-1.23) were strongly associated with a nonscreening indication with similar results for ≤9-month surveillance interval. Screening indication and >9-month surveillance intervals were more common in more recent years.ConclusionVariability in surveillance indications across facilities in the United States supports including indications beyond screening in studies evaluating surveillance mammography effectiveness and demonstrates the need for standardization.     

Compliance With Screening Mammography Guidelines After a False-Positive Mammogram

PurposeTo assess whether women with a false-positive mammogram who do return for screening are less likely to be compliant with screening mammography guidelines than are women with a negative mammogram.MethodsThis institutional review board-approved, HIPAA-compliant retrospective cohort study includes women >40 years old who received 9,385 consecutive, nonbaseline screening mammograms between December 1, 2012 and December 31, 2013. Using linear regression, we evaluated differences in time between mammograms by prior recall status, after adjusting for location of current mammogram (outpatient office versus mobile unit) and age. Using Fisher's exact test, we evaluated the association between compliance with screening guidelines and the recall status on prior mammogram, and compared by location the proportions of noncompliant women who were recalled from prior mammogram.ResultsTime between mammograms does not differ based on prior recall status (P = .83). There is no association between compliance with screening mammography guidelines and recall status on prior mammogram (ACR guidelines P = .398, United States Preventive Services Task Force guidelines P = .416). Noncompliant women recalled on prior mammogram are more likely to undergo mammography at the outpatient office rather than the mobile unit (ACR guidelines P = .0004, United States Preventive Services Task Force guidelines P = .0032).ConclusionsA prior false-positive mammogram is not a significant deterrent to compliance with screening guidelines in those women who return for screening.     

Mammography and breast sonography in transsexual women

Data on the necessity of performing screening mammographies in transsexual women are lacking. The main objective of this study was to assess the possibility to perform mammography and breast sonography in transsexual women.Fifty Dutch-speaking transsexual women were interviewed about the following: attitude towards mammography and breast sonography, importance attributed to and satisfaction with breast appearance, opinion about the necessity of breast check-up, expectations regarding discomfort during the exams and knowledge about the breast surgery. A fasting blood sample, clinical breast exam, mammography and breast sonography were performed. At mammography the following parameters were noted: density, technical quality, location of the prostheses, presence of any abnormalities and painfulness. At sonography the following parameters were recorded: density, presence of cysts, visualisation of retro-areolar ducts or any abnormalities.Twenty-three percent of patients are not aware of the type of breast implants and 79% do not know their position to the pectoral muscles. Patient satisfaction with the appearance of their breasts was rather high (7.94 on a scale of 0-10). Mean expected and experienced pain from mammography was low (4.37 and 2.00 respectively). There was no statistically significant difference in expected pain between those who already had mammography and those who did not. There was a significant positive correlation between the expected and the experienced pain.Mammography and breast sonography were technically feasible and no gross anomalies were detected. Since both exams were judged as nearly painless, 98% of transsexual women intended to come back if they would be invited. Since breast cancer risk in transsexual women is largely unknown and breast exams are very well accepted, breast screening habits in this population should not differ from those of biological women.     

Mammography Clinical Image Quality and the False Positive Rate in a Canadian Breast Cancer Screening Program

Purpose

The study sought to determine if mammography quality is associated with the false positive (FP) rate in the Quebec breast cancer screening program in 2004 and 2005.