Impact of the California Breast Density Law on Primary Care Physicians

PurposeTo investigate primary physician awareness of the California Breast Density Notification Law and its impact on primary care practice.MethodsAn online survey was distributed to 174 physicians within a single primary care network system 10 months after California’s breast density notification law took effect. The survey assessed physicians’ awareness of the law, perceived changes in patient levels of concern about breast density, and physician comfort levels in handling breast density management issues.ResultsThe survey was completed by 77 physicians (45%). Roughly half of those surveyed (49%) reported no knowledge of the breast density notification legislation. Only 32% of respondents noted an increase in patient levels of concern about breast density compared to prior years. The majority were only “somewhat comfortable” (55%) or “not comfortable” (12%) with breast density questions, and almost one-third (32%) had referred patients to a breast health clinic for these discussions. A total of 75% of those surveyed would be interested in more specific education on the subject.ConclusionsAwareness among primary care clinicians of the California Breast Density Notification Law is low, and many do not feel comfortable answering breast density-related patient questions. Breast imagers and institutions may need to devote additional time and resources to primary physician education in order for density notification laws to have significant impact on patient care.     

Breast Density Awareness,Knowledge, and Attitudes Among US Women: National Survey Results Across 5 Years

PurposeTo assess changes in breast density (BD) awareness, knowledge, and attitudes among US women over a period of 5 years.MethodsUsing a probability-based web panel representative of the US population, we administered an identical BD survey in 2012 and 2017 to women aged 40 to 74 years.ResultsIn 2017, 65.8% had heard of BD (versus 57.5% in 2012; P = .0002). BD awareness in both 2012 and 2017 was significantly associated with race, income, and education. Among women aware of BD in 2017, 76.5% had knowledge of BD’s relationship to masking (versus 71.5% in 2012; P = .04); 65.5% had knowledge of BD’s relationship to cancer risk (versus 58.5%; P = .009); and 47.3% had discussed BD with a provider (versus 43.1% in 2012; P = .13). After multivariable adjustment, residence in a state with BD legislation was associated in 2017 with knowledge of BD’s relationship to risk but not to masking. Most women wanted to know their BD (62.5% in 2017 versus 59.8% in 2012; P = .46); this information was anticipated to cause anxiety in 44.8% (versus 44.9% in 2012; P = .96); confusion in 35.9% (versus 43.0%; P = .002); and feeling informed in 89.7% (versus 90.4%; P = .64). Over three-quarters supported federal BD legislation in both surveys. Response rate to the 2017 survey was 55% (1,502 of 2,730) versus 65% (1,506 of 2,311) in 2012.ConclusionAlthough BD awareness has increased, important disparities persist. Knowledge of BD’s impact on risk has increased; knowledge about masking and BD discussions with providers have not. Most women want to know their BD, would not feel anxious or confused as a result of knowing, and would feel empowered to make decisions. The federal BD notification legislation presents an opportunity to improve awareness and knowledge and encourage BD conversations with providers.     

The Impact of Breast Density Reporting Laws on Women’s Awareness of Density-Associated Risks and Conversations Regarding Supplemental Screening With Providers

Objective

We conducted a national survey to understand the impact of state-level density reporting laws on women’s level of density risk awareness and their engagement in conversations with providers regarding supplemental screening.

Impact of the New Jersey Breast Density Law on Imaging and Intervention Volumes and Breast Cancer Diagnosis

PurposeIncreased breast density is acknowledged as an independent risk factor for breast cancer and may obscure malignancy on mammography. Approximately half of all mammograms depict dense breasts. Legislation related to mandatory breast density notification was first enacted in Connecticut in 2009. On May 1, 2014, New Jersey joined other states with similar legislation. The New Jersey breast density law (NJBDL) mandates that mammography reports acknowledge the relevance and masking effect of mammographic breast density. The aim of this study was to assess the impact of the NJBDL at one of the state’s largest ACR-accredited breast centers.MethodsA retrospective chart review was performed to determine changes in imaging and intervention utilization and modality of cancer diagnosis after enactment of the legislation. Data for the present study were extracted from a review of all patients with core biopsy–proven malignancy at a large outpatient breast center between November 1, 2012, and October 31, 2015. Data were divided into the 18-month period before the implementation of the NJBDL (November 1, 2012 to April 30, 2014) and the 18-month period after passage of the law (May 1, 2014 to October 31, 2015).ResultsScreening ultrasound increased significantly after the implementation of the NJBDL, by 651% (1,530 vs 11,486). MRI utilization increased by 59.3% (2,595 vs 4,134). A total of 1,213 cancers were included in the final analysis, 592 in the first time period and 621 after law implementation. Breast cancer was most commonly detected on screening mammography, followed by diagnostic mammography with ultrasound for palpable concern, in both time periods. Of the 621 cancers analyzed, 26.1% (n = 162) were found in patients 50 years of age or younger. Results demonstrated that with respect to how malignancies were detected, age and average mammographic density were both statistically significant (P = .002).ConclusionsThe NJBDL succeeded in publicizing the masking effect of dense breasts. The number of supplemental screening ultrasound and MRI examinations increased after the implementation of this legislation. An efficacy analysis affirmed the high sensitivity of screening MRI compared with other modalities. The use of MRI increased core biopsy efficiency and reduced the number of biopsies needed per cancer diagnosed.     

Between-Race Differences in Supplemental Breast Cancer Screening Before and After Breast Density Notification Law

Guidelines recommend supplemental breast cancer screening for women at increased breast cancer risk; however, the passage of breast density notification laws may lead to supplemental screening that is incongruent with women’s risk. We examined supplemental screening (ie, MRI, ultrasound, or tomosynthesis within 6 months of screening mammogram) among a sample of 2,764 African American (AA) and 691 European American (EA) women with negative or benign screening mammograms for whom we had data from both before and after implementation of breast density notification laws in the state of Michigan. Results indicated a 5-fold increase (from 0.14% to 0.7% of women) in supplemental screening among screen-negative women after passage of the law, driven in large part by an increase in supplemental screening among AA women. Breast density was more predictive of supplemental screening and had a marginally greater explanatory role in between-race differences in supplemental screening after passage of the law. Subgroup analyses (n = 250) indicated that whereas 5-year breast cancer risk was positively associated with supplemental screening before the law and negatively associated after the law for EA women, 5-year risk was not associated with supplemental screening either before or after passage of the law for AA women. Our findings suggest that whereas passage of the breast density notification laws may have motivated supplemental screening among AA women in particular, it lessened the consideration of breast cancer risk in supplemental screening decision making.     

Patient Awareness of Breast Density and Interest in Supplemental Screening Tests: Comparison of an Academic Facility and a County Hospital

PurposeThe aim of this study was to measure women’s knowledge of breast density and their attitudes toward supplemental screening tests in the setting of the California Breast Density Notification Law at an academic facility and a county hospital, serving women with higher and lower socioeconomic status, respectively.MethodsInstitutional review board exemptions were obtained. A survey was administered during screening mammography at two facilities, assessing women’s awareness of and interest in knowing their breast density and interest in and willingness to pay for supplemental whole breast ultrasound and contrast-enhanced spectral mammography (CEMG). The results were compared by using Fisher exact tests between groups.ResultsA total of 105 of 130 and 132 of 153 women responded to the survey at the academic and county facilities, respectively. Among respondents at the academic and county facilities, 23% and 5% were aware of their breast density, and 94% and 79% wanted to know their density. A majority were interested in supplemental ultrasonography and CEMG at both sites; however, fewer women had a willingness to pay for the supplemental tests at the county hospital compared with those at the academic facility (22% and 70%, respectively, for ultrasound, P < .0001; 20% and 65%, respectively, for CEMG, P < .0001).ConclusionsBoth groups of women were interested in knowing their breast density and in supplemental screening tests. However, women at the county hospital were less willing to incur out-of-pocket expenses, suggesting a potential for a disparity in health care access for women of lower socioeconomic status after the enactment of breast density notification legislation.     

Imaging-Guided Core-Needle Breast Biopsy: Impact of Meditation and Music Interventions on Patient Anxiety,Pain, and Fatigue

PurposeTo evaluate the impact of guided meditation and music interventions on patient anxiety, pain, and fatigue during imaging-guided breast biopsy.MethodsAfter giving informed consent, 121 women needing percutaneous imaging-guided breast biopsy were randomized into three groups: (1) guided meditation; (2) music; (3) standard-care control group. During biopsy, the meditation and music groups listened to an audio-recorded, guided, loving-kindness meditation and relaxing music, respectively; the standard-care control group received supportive dialogue from the biopsy team. Immediately before and after biopsy, participants completed questionnaires measuring anxiety (State-Trait Anxiety Inventory Scale), biopsy pain (Brief Pain Inventory), and fatigue (modified Functional Assessment of Chronic Illness Therapy-Fatigue). After biopsy, participants completed questionnaires assessing radiologist–patient communication (modified Questionnaire on the Quality of Physician–Patient Interaction), demographics, and medical history.ResultsThe meditation and music groups reported significantly greater anxiety reduction (P values < .05) and reduced fatigue after biopsy than the standard-care control group; the standard-care control group reported increased fatigue after biopsy. The meditation group additionally showed significantly lower pain during biopsy, compared with the music group (P = .03). No significant difference in patient-perceived quality of radiologist–patient communication was noted among groups.ConclusionsListening to guided meditation significantly lowered biopsy pain during imaging-guided breast biopsy; meditation and music reduced patient anxiety and fatigue without compromising radiologist–patient communication. These simple, inexpensive interventions could improve women’s experiences during core-needle breast biopsy.     

Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.     

The diverse pathology and kinetics of mass, nonmass, and focus enhancement on MR imaging of the breast

Purpose:

To compare the pathology and kinetic characteristics of breast lesions with focus‐, mass‐, and nonmass‐like enhancement.

Materials and Methods:

A total of 852 MRI detected breast lesions in 697 patients were selected for an IRB approved review. Patients underwent dynamic contrast enhanced MRI using one pre‐ and three to six postcontrast T₁‐weighted images. The “type” of enhancement was classified as mass, nonmass, or focus, and kinetic curves quantified by the initial enhancement percentage (E₁), time to peak enhancement (T_peak), and signal enhancement ratio (SER). These kinetic parameters were compared between malignant and benign lesions within each morphologic type.

Results:

A total of 552 lesions were classified as mass (396 malignant, 156 benign), 261 as nonmass (212 malignant, 49 benign), and 39 as focus (9 malignant, 30 benign). The most common pathology of malignant/benign lesions by morphology: for mass, invasive ductal carcinoma/fibroadenoma; for nonmass, ductal carcinoma in situ (DCIS)/fibrocystic change(FCC); for focus, DCIS/FCC. Benign mass lesions exhibited significantly lower E₁, longer T_peak, and lower SER compared with malignant mass lesions (P < 0.0001). Benign nonmass lesions exhibited only a lower SER compared with malignant nonmass lesions (P < 0.01).

Conclusion:

By considering the diverse pathology and kinetic characteristics of different lesion morphologies, diagnostic accuracy may be improved. J. Magn. Reson. Imaging 2011;33:1382–1389. © 2011 Wiley‐Liss, Inc.     

Advances in Myocardial Perfusion MR Imaging: Physiological Implications,the Importance of Quantitative Analysis,and Impact on Patient Care in Coronary Artery Disease

Stress myocardial perfusion imaging (MPI) is the preferred test in patients with intermediate-to-high clinical likelihood of coronary artery disease (CAD) and can be used as a gatekeeper to avoid unnecessary revascularization. Cardiac magnetic resonance (CMR) has a number of favorable characteristics, including: (1) high spatial resolution that can delineate subendocardial ischemia; (2) comprehensive assessment of morphology, global and regional cardiac functions, tissue characterization, and coronary artery stenosis; and (3) no radiation exposure to patients. According to meta-analysis studies, the diagnostic accuracy of perfusion CMR is comparable to positron emission tomography (PET) and perfusion CT, and is better than single-photon emission CT (SPECT) when fractional flow reserve (FFR) is used as a reference standard. In addition, stress CMR has an excellent prognostic value. One meta-analysis study demonstrated the annual event rate of cardiovascular death or non-fatal myocardial infarction was 4.9% and 0.8%, respectively, in patients with positive and negative stress CMR. Quantitative assessment of perfusion CMR not only allows the objective evaluation of regional ischemia but also provides insights into the pathophysiology of microvascular disease and diffuse subclinical atherosclerosis. For accurate quantification of myocardial perfusion, saturation correction of arterial input function is important. There are two major approaches for saturation correction, one is a dual-bolus method and the other is a dual-sequence method. Absolute quantitative mapping with myocardial perfusion CMR has good accuracy in detecting coronary microvascular dysfunction. Flow measurement in the coronary sinus (CS) with phase contrast cine CMR is an alternative approach to quantify global coronary flow reserve (CFR). The measurement of global CFR by quantitative analysis of perfusion CMR or flow measurement in the CS permits assessment of microvascular disease and diffuse subclinical atherosclerosis, which may provide improved prediction of future event risk in patients with suspected or known CAD. Multi-institutional studies to validate the diagnostic and prognostic values of quantitative perfusion CMR approaches are required.