Mammography screening

Exclusive biannual mammography screening for women ages 50-69 years reduces the mortality from breast cancer among participants by 35%. Compared with 50% of clinically detected cancers, only 20% of carcinomas detected in screening have nodal metastases, and up to 55% of screening carcinomas are in the T1 stage of "minimal cancer." In many European countries (including Sweden, Norway, the Netherlands, and Great Britain), mammography screening programmes have been established for more than 10 years. In Germany, the aim is to establish, by 2008, a nationwide organised programme on the basis of the European Guidelines for Quality Assurance. This goal requires 80-100 mammography screening units. The first screening units went into use in 2005. Women between 50 and 69 years are invited to participate in 2-year intervals.     

First-trimester screening

Screening for fetal chromosome abnormalities, particularly for trisomy 21, has made dramatic advances. Better screening demonstrates that "high-risk" patients--particularly over age 35--can have lower risk of defects than younger unscreened women. This has caused reduction of amniocentesis for older patients and made screening available for younger patients who have the universal 2% to 3% risk. This means lower procedural-related losses of normal fetuses, and better resource allocation. The trend toward first-trimester detection of structural defects continues; a normal survey is reassuring and helps exclude major defects. Based on screening results, patients can be triaged into early follow-up and possible amniocentesis as 14 to 16 weeks, or a later detailed anatomic survey at 18 to 20 weeks.     

Completion of colorectal cancer screening in women attending screening mammography

RATIONALE AND OBJECTIVES: The American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF) recommend colorectal cancer (CRC) screening to begin at age 50 in individuals at average risk for CRC. To estimate rate at which women eligible for CRC screening at the time of screening mammography attendance later completed in CRC screening, we retrospectively evaluated CRC screening utilization in women who underwent screening mammography at our institution. MATERIALS AND METHODS: We retrospectively identified 3357 women between the ages of 50 to 75 who received screening mammography in 1998 at a single academic medical center using the institution's Radiology Information System (RIS). Additional information collected from the institution's Health System Data Warehouse and the Radiology department's mammography quality assurance data included mammography results, Breast Imaging Reporting and Database System (BI-RADS) classification of mammography findings, recommendation for screening mammography follow-up, insurance status, and CRC screening utilization after screening mammography. After excluding women who were current with CRC screening at the time of mammography, we determined the proportion of eligible women who completed CRC screening after mammography. Age, insurance type, BI-RADS code, and recommendation code were evaluated as potential predictors of CRC screening completion in eligible women. RESULTS: Of the 3357 women between the ages of 50 and 75 who received screening mammography in 1998, only 414 (12.3%) were current with CRC screening at the time of screening mammography. Of the remaining 2943 women who were eligible for CRC screening at the time of screening mammography, 142 (4.8%) subsequently completed CRC screening. Average time to completion of CRC screening after screening mammography is 35.4 months (range, 0.27-64.9). Managed care insurance was the only significant predictor of CRC screening completion after screening mammography in eligible women after adjusting for other variables (adjusted OR 1.73, 95% CI 1.21-2.47, P < .0001). Neither BI-RADS classification nor postmammography recommendations were significantly associated with CRC screening completion. CONCLUSIONS: Prevalence studies have demonstrated that women who were compliant with screening mammography were more compliant with CRC screening. Our data suggest that despite this increased compliance, overall incidence of CRC screening is low in the screening mammography population.     

Preparticipation cardiovascular screening

Regular aerobic exercise provides many health benefits regardless of age, and should be promoted by health care providers to all patients. In older athletes, coronary artery disease is the most common cause of sudden death. There is widespread consensus, however, that the overall health benefits derived from exercise outweigh the risks of participation. Screening should focus on identifying signs and symptoms of underlying cardiovascular disease by obtaining a personal and family history and performing a focused physical examination according to the recommendations of the AHA. Exercise testing is recommended in males older than 40 and females older than 50, and individuals with cardiac risk factors. Cardiovascular PPE screening in young athletes remains a challenge, because potentially fatal abnormalities are uncommon and in some cases are undetectable without sophisticated testing. Most sudden cardiac deaths in athletes are caused by anomalies that are clinically silent, are rare, or are difficult to detect by history and physical examination. Many athletes may not experience symptoms consistent with heart disease or may not report family histories of sudden cardiac death. Important clues to a cardiac abnormality include history of syncope, chest pain, and family history of sudden death. Any underlying condition suspected on the basis of history or physical examination requires further diagnostic evaluation before the athlete can be cleared for activity. Currently there is considerable variability and inconsistency among state requirements for PPEs. A national adoption of a more uniform PPE screening process should be encouraged. The screening process should include the AHA's cardiovascular screening recommendations, as this would assist in closing the gap between screening practices recommended by sports medicine experts and the reality of current screening practices. Although the extent of screening continues to be debated, clinical guidelines for performing PPEs and determining clearance have been established. Without a uniform implementation of the current guidelines, it will not be possible to assess the value of the current cardiovascular screening recommendations in detecting and preventing cardiovascular death in young athletes. Physicians should be aware of the emerging role of genetic testing for cardiovascular diseases in athletes with a family history of heart disease or sudden death. Advances in the diagnosis and understanding of cardiovascular disease may provide better tools for preventing sudden death of young athletes in the future [11].     

Ovarian cancer screening

Ovarian cancer will kill more women this year than cancer of the uterine corpus and cervix combined. Outcome is stage dependent. At stage IV, the five year survival rate is about 4.5%, but at stage I it may be well over 90%. Overall, regardless of stage, about 30% of women with ovarian cancer will be alive five years after its diagnosis. The fact that changes in treatment over the past two decades have done little to alter these depressing figures has led to a reassessment of our approach to this problem. It has been proposed that earlier diagnosis of the condition will lead to improved patient outcome. Because the disease is asymptomatic in its earliest stages in the majority of cases, this has prompted the search for a reliable screening test that could be used to detect the cancer when it is still confined within the capsule of the ovary. This paper discusses these issues, assesses the different techniques available to screen for ovarian cancer, and comments on possible future developments.     

Passive magnetic screening

It is shown that a passive magnetic shield for a 1.5-T whole-body magnet requires about 20 tons of iron. Moreover, to first order, the amount of shielding material is independent of the radius of the shield. The choice between a thick shield fitting tightly round the magnet and a thinner shield of larger radius is determined by considerations of available space and the need for the highest uniformity of field in the bore. Very high permeability materials such as mu-metal are useful only in special circumstances. Multiple shields are valuable if a high degree of shielding is required, but the spacing between the shields needs careful attention. Although exact reciprocity of internal and external shielding is not found in the general case, the degree of shielding will be of the same order in both cases. The complete behavior of cylindrical shields around superconducting magnets can be determined by analytical solution of Maxwell's equations; for less regular shapes, solutions may be determined numerically by computer.     

Lung cancer screening

Lung cancer screening with CT remains controversial. Lung cancer is the leading cause of cancer death. To date, no screening test has been demonstrated to reduce mortality. Given the large population of adult cigarette smokers and former smokers worldwide, there is a large population at risk for lung cancer. While a lot has been learned from prospective single-arm cohort studies about the feasibility of performing annual CT to screen for lung cancer, many questions have also been raised. While we know that screening for lung cancer with CT detects many small nodules, with up to half the subjects having a positive baseline screen, and up to 75% of subjects having a positive screen at least once if screened annually for 5 years, the great majority of these nodules exhibit benign biologic behavior. The innumerable small nodules detected with screening CT, and diagnostic chest CT in general, present a daily clinical challenge, and result in extensive medical resource utilization and additional radiation exposure. Algorithms for how and when to follow small nodules detected on CT are in evolution. Ongoing studies are designed to determine if lung cancer screening with CT reduces lung cancer mortality.     

Lung cancer screening

Lung cancer screening with CT remains controversial. Lung cancer is the leading cause of cancer death. To date, no screening test has been demonstrated to reduce mortality. Given the large population of adult cigarette smokers and former smokers worldwide, there is a large population at risk for lung cancer. While a lot has been learned from prospective single-arm cohort studies about the feasibility of performing annual CT to screen for lung cancer, many questions have also been raised. While we know that screening for lung cancer with CT detects many small nodules, with up to half the subjects having a positive baseline screen, and up to 75% of subjects having a positive screen at least once if screened annually for 5 years, the great majority of these nodules exhibit benign biologic behavior. The innumerable small nodules detected with screening CT, and diagnostic chest CT in general, present a daily clinical challenge, and result in extensive medical resource utilization and additional radiation exposure. Algorithms for how and when to follow small nodules detected on CT are in evolution. Ongoing studies are designed to determine if lung cancer screening with CT reduces lung cancer mortality.     

Characteristics and screening outcome of women referred twice at screening mammography

Objectives

To determine the characteristics and screening outcome of women referred twice at screening mammography.

Methods

We included 424,703 consecutive screening mammograms and collected imaging, biopsy and surgery reports of women with screen-detected breast cancer. Review of screening mammograms was performed to determine whether or not an initial and second referral comprised the same lesion.

Results

The overall positive predictive value of referral for cancer was 38.6% (95% CI 37.3-39.8%). Of 147 (2.6%) women referred twice, 86 had been referred for a different lesion at second referral and 32 of these proved malignant (37.2%, 95% CI 27.0-47.4%). Sixty-one women had been referred twice for the same lesion, of which 22 proved malignant (36.1%, 95% CI 24.1-48.0%). Characteristics of these women were comparable to women with cancer diagnosed after first referral. Compared with women without cancer at second referral for the same lesion, women with cancer more frequently showed suspicious densities at screening mammography (86.4% vs 53.8%, P?=?0.02) and work-up at first referral had less frequently included biopsy (22.7% vs 61.5%, P?=?0.004).

Conclusions

Cancer risk in women referred twice for the same lesion is similar to that observed in women referred once, or referred for a second time but for a different lesion.

Key Points

? Cancer risk was 36% for lesions referred twice at screening mammography ? The cancer risk was similar for lesions referred only once at screening ? Densities at first referral were associated with increased cancer risk at second referral ? No biopsy at first referral was associated with increased cancer risk at second referral ? Patient and tumour characteristics were similar for women with and without diagnostic delay     

再次进行乳腺摄影筛查女性的特点与筛查结果

目的研究再次进行乳腺摄影筛查女性的特点和筛查结果。方法回顾性收集424703例连续的乳腺摄影筛查影像资料,以及发现乳腺癌的活检结果和手术报告。研究乳腺摄影情况,确定首次与二次检查是否存在相同的病变。结果总体的乳腺癌阳性预测值为38.6%(95%CI:37.3%～39.8%)。147例(2.6%)进行再次筛查的病人中,86例再次检查时存在不同的病变,其中32例为恶性(37.2%,95%CI:27.0%～47.4%)。61例女性再次检查的目的为相同病变,其中22例为恶性(36.1%,95%CI:24.1%～48.0%)。比较这些女性与首次乳腺摄影诊断为癌症的特点。与再次检查时相同病灶不为肿瘤者相比,患癌症者通常在乳腺摄影中表现为可疑高密度影(86.4%与53.8%,P=0.02),首次检查工作流程中的活检率较低(22.7%与61.5%,P=0.004)。结论对于再次进行乳腺筛查的女性,无论是由于相同病灶还是不同病灶而进行,再次筛查的恶性肿瘤风险与首次筛查者相当。     

The added value of screening mammography in improved screening for other cancers

As part of day-to-day practice, the most frequent role of the radiologist is to provide diagnostic information derived from imaging that will help the clinician better manage patient care. In essence, radiologists are reimbursed for the information we provide. The value of diagnostic information, however, extends beyond strict clinical and monetary value.The objectives of this paper are to provide the framework for understanding the “value” of diagnostic imaging. The article focuses on the application of these concepts using examples from the literature with particular emphasis on screening and suggests using a screening test experience as a means of improving health behavior.     

Variations in screening outcome among pairs of screening radiologists at non-blinded double reading of screening mammograms: a population-based study

Objectives

Substantial inter-observer variability in screening mammography interpretation has been reported at single reading. However, screening results of pairs of screening radiologists have not yet been published. We determined variations in screening performances among pairs of screening radiologists at non-blinded double reading.

Methods

We included pairs of screening radiologists with at least 7,500 screening examinations per pair, obtained between 1997 and 2011. During 2-year follow-up, breast imaging reports, surgical reports and pathology results were collected of all referred women and interval cancers. Referral rate, cancer detection rate, positive predictive value and sensitivity were calculated for each pair.

Results

A total of 310,906 screening mammograms, read by 26 pairs of screening radiologists, were included for analysis. The referral rate ranged from 1.0 % (95 % CI 0.8 %–1.2 %) to 1.5 % (95 % CI 1.3 %–1.8 %), the cancer detection rate from 4.0 (95 % CI 2.8–5.2) to 6.3 (95 % CI 4.5–8.0) per 1,000 screens. The programme sensitivity and positive predictive value of referral ranged from 55.1 % (95 % CI 45.1 %–65.1 %) to 81.5 % (95 % CI 73.4 %–89.6 %) and from 28.7 % (95 % CI 20.8 %–36.6 %) to 49.5 % (95 % CI 39.7 %–59.3 %), respectively.

Conclusion

We found significant variations in screening outcomes among pairs of screening radiologists at non-blinded double reading. This stresses the importance of monitoring screening results on a local scale.

Key Points

? Substantial inter-observer variability in screening mammography interpretation is known at single reading ? Population-based study showed significant variations in outcomes among pairs of screening radiologists ? Local monitoring and regular feedback are important to optimise screening outcome     

CAD in screening mammography

OBJECTIVE: The benefit and cost of computer-assisted detection (CAD) mammography screening remains a topic of great interest in breast imaging. Our purpose is to reflect on and interleave two articles in this issue of the AJR that highlight the difficulty in assessing the actual benefit of using CAD from either retrospective or prospective studies. CONCLUSION: This commentary describes the possible benefit and some of the issues associated with the clinical use of current CAD technology while emphasizing the expectation of and need for future improvements in CAD performance.