Results of MRI Screening for Breast Cancer in High-Risk Patients with LCIS and Atypical Hyperplasia

Background Magnetic resonance imaging (MRI) can detect breast cancer in high-risk patients, but is associated with a significant false-positive rate resulting in unnecessary breast biopsies. More data are needed to define the role of MRI screening for specific high-risk groups. We describe our experience with MRI screening in patients with atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS). Methods We retrospectively reviewed data from our high-risk screening program prospective database for the period from April 1999 (when screening MRI was first performed at our institution) to July 2005. Patients with AH or LCIS demonstrated on previous surgical biopsy were identified. All patients underwent yearly mammography and twice yearly clinical breast examination. Additional screening MRI was performed at the discretion of the physician and patient. Results We identified 378 patients; 126 had AH and 252 had LCIS. Of these, 182 (48%) underwent one or more screening MRIs (mean, 2.6 MRIs; range, 1–8) during this period, whereas 196 (52%) did not. Those who had MRIs were younger (P < 0.001) with stronger family histories of breast cancer (P = 0.02). In MRI-screened patients, 55 biopsies were recommended in 46/182 (25%) patients, with 46/55 (84%) biopsies based on MRI findings alone. Cancer was detected in 6/46 (13%) MRI-generated biopsies. None of the six cancers detected on MRI were seen on recent mammogram. All six cancers were detected in five patients (one with bilateral breast cancer) with LCIS; none were detected by MRI in the AH group. Thus, cancer was detected in 5/135 (4%) of patients with LCIS undergoing MRI. The yield of MRI screening overall was cancer detection in 6/46 (13%) biopsies, 5/182 (3%) MRI-screened patients and 5/478 (1%) total MRIs done. In two additional MRI-screened patients, cancer was detected by a palpable mass in one, and on prophylactic surgery in the other and missed by all recent imaging studies. For 196 non-MRI-screened patients, 21 (11%) underwent 22 biopsies during the same period. Eight of 22 (36%) biopsies yielded cancer in seven patients. All MRI-detected cancers were stage 0–I, whereas all non-MRI cancers were stage I–II. Conclusion Patients with AH and LCIS selected to undergo MRI screening were younger with stronger family histories of breast cancer. MRI screening generated more biopsies for a large proportion of patients, and facilitated detection of cancer in only a small highly selected group of patients with LCIS.     

Routine screening for local recurrence following breast-conserving therapy for cancer with dynamic contrast-enhanced magnetic resonance imaging of the breast

Background: Dynamic contrast-enhanced magnetic resonance imaging (MRI) of the breast is highly sensitive for the diagnosis of primary breast malignancy. We investigated the clinical application of dedicated dynamic breast MR for routine screening for local recurrence following breast-conserving therapy. Methods: Patients underwent a single dynamic MR of the breast routinely in the period 1 to 2 years following treatment, or earlier if recurrence was suspected. A biopsy was performed if there was suspicion of recurrence on MR. Results: One hundred and five patients with a median age of 58 years (range 50 to 65 years) were recruited for the study. Sixteen biopsies were performed and nine recurrences were confirmed histologically. Patients not undergoing biopsy have been followed up for a median of 341 days (range 168 to 451 days) following the MR. The sensitivity for clinical examination, mammography, examination combined with mammography, and MRI alone for the detection of recurrent cancer were 89%, 67%, 100%, and 100%, respectively, and the specificity was 76%, 85%, 67%, and 93%. Conclusion: Combined clinical examination and mammography are as sensitive as dedicated dynamic MR of the breast for the detection of locoregional recurrence, but breast MRI is associated with a far greater specificity. Therefore, dedicated dynamic breast MRI should be used when there is clinical or mammographic suspicion of recurrence to confirm or refute its presence.Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

Trends in breast cancer at a county hospital

Breast cancer mortality has changed dramatically with improvements in screening techniques. Mammography is essential for early detection; however, its contribution to the survival benefit in young women is questionable. We report our experience in breast biopsies at a county teaching hospital with a traditionally younger patient population. Institutional review board approval was obtained prior to data collection. A total of 550 breast biopsies were conducted between 1995 and 2000. Data regarding age, method of breast biopsy, and pathology was reviewed. One hundred twenty of 550 patients (21.8%) had breast carcinoma detected on breast biopsies with the predominant histologic subtype being invasive ductal carcinoma. The mean age of patients with carcinoma was 52.8 years, whereas that of patients with benign breast disease was 43.6 years (P < 0.05). Forty-three per cent of all breast cancers occurred in women under the age of 50 years. During the study period, there was neither an increase in the number of breast biopsies performed per year nor a decrease in the average age of women with breast cancer. However, observing a significant percentage of breast cancer patients under 50 years old, our data suggest the importance of strict adherence to current screening recommendations including self-breast examination and yearly mammography.     

Stratification of palpable and nonpalpable breast cancer by method of detection and age

Background: Methods used to diagnose breast cancer in women under the age of 50 years are somewhat controversial. To determine the relationship between type and stage of breast cancer, clinical presentation, and age, we reviewed breast cancer diagnosed at our institution during a recent 3-year period. Methods: Records from 589 consecutive excisional biopsies and 372 needle placement biopsies performed over a 3-year period were reviewed. Carcinomas were staged according to the TNM system and results compared usingx ². Results: Breast carcinoma was diagnosed in 118 women during the study period, 33% in patients under 50 years of age. Breast cancer diagnosed by mammography in all age groups was more likely to be noninvasive than that diagnosed by physical examination (p<0.05). The few invasive cancers diagnosed by mammography in women under age 50 were lower in stage than those diagnosed by physical examination, although not by a statistically significant amount (p=0.125). Breast cancer diagnosed by mammography in women 50 years and older was significantly lower in stage than that diagnosed by physical examination (p<0.05). Conclusions: Invasive carcinoma detected as a nonpalpable lesion by mammography was earlier in stage than invasive carcinoma detected by physical examination, including in women under 50 years of age, although the number of invasive cancers detected in younger women was quite small. The role of mammography in this younger age group remains to be defined. Disclaimer: The viewpoints expressed herein are those of the authors and do not necessarily represent those of the Navy or Department of Defense.     

THE POTENTIAL IMPACT OF BREAST CANCER SCREENING IN HONG KONG

Background : Breast cancer is the second most common cancer and cause of death in women from Hong Kong. The Well Women Clinic at Kwong Wah Hospital offers breast cancer screening (physical examination and mammography) for women over 40 years of age. Methods : Results of screening over a 2-year period revealed an overall malignancy detection rate of 2.6 per 1000 screens with a strong selection bias for symptomatic women. Results : Screening only slightly increased the proportion of stage I cancers detected; of the malignancies detected, a significant percentage were in situ cancers with doubtful effects on breast cancer mortality. Teamwork and communication were useful in keeping a low referral rate to the surgical clinic of 6.1%, as well as a low biopsy rate for mammographic abnormalities. Conclusions : A re-evaluation of the real risk of breast cancer in young women together with the lack of proven value from screening has suggested a need for reconsideration of offering screening to women 40 years and over in Hong Kong.     

Relation between clinical and mammographic diagnosis of breast problems and the cancer/biopsy rate

Objective

To determine the sensitivity of mammographic and clinical assessment of breast problems, independent of one another, on the ratio of cancers found to biopsies performed (cancer/biopsy rate).

Design

A review of diagnoses from prospectively recorded and independently assessed clinical and mammographic examinations.

Setting

The breast clinic in a university-affiliated hospital.

Patients

Patients were considered in two age groups — under 50 years and 50 years and over; 1251 patients underwent breast biopsy between September 1976 and November 1994 after clinical assessment and mammography.

Main Outcome Measure

The cancer diagnosis rate found on biopsy as a result of clinical and mammographic findings.

Results

In both age groups, mammography was significantly (p < 0.001) more sensitive than clinical assessment in cancer diagnosis but gave a significantly (p < 0.0001) higher rate of false-positive results. The cancer diagnosis rate was highest when lesions were assessed both clinically and mammographically as malignant but was of diagnostic benefit only to women in the under-50-year age group. The cancer rate was 12% when both assessments indicated a benign process and only 2% in women under age 50 years with clinically benign conditions who did not have mammography. Twenty-one percent of the biopsies were obtained in women with clinically normal breasts because of a mammographic abnormality and 17% of all the cancers found were clinically occult.

Conclusions

The sensitivity of clinical assessment, particularly in premenopausal women is low and the false-positive mammography rate is high, but the cancer/biopsy rate is sufficiently high to warrant breast biopsy if either diagnostic modality suggests a cancer. When neither modality suggests cancer, the cancer/biopsy rate is 12% in both age groups.     

The changing mammogram. A primary indication for needle localization biopsy

Screening mammography results in improved detection and survival for women with breast cancer. Interval mammographic changes may be one of the major indications for biopsy. Four hundred fifty-two needle localization biopsies carried out for microcalcifications, mass, asymmetric density, or a combination of calcifications with mass or asymmetric density detected 95 cancers (21%). Interval mammographic changes detected 35 cases (17.9%). Invasive cancers constituted 51% of the initial group but only 34% of the cancers detected because of interval change. Benign breast disease occurred in 160 of 195 women who had undergone biopsy because of interval changes. These changes continued into the postmenopausal period. Hyperplasia and/or atypia was found in 57 (35%) of 160 of the interval group. Interval mammographic abnormalities detect significant pathologic changes in the breast and should be considered a major indication for breast biopsy.     

Disparities in the uptake of digital breast tomosynthesis for breast cancer screening: A retrospective cohort study

We present a retrospective cohort study evaluating the utilization and effectiveness of digital breast tomosynthesis (DBT) for breast cancer screening with a focus on racial differences. 46,236 females underwent screening mammography between 4/1/2013 and 3/30/2020, during which there was an increase in DBT utilization from 18.8% in year 1 to 89.6% in year 7. Black and Asian women were significantly less likely to have a screening study with DBT compared to White women. Overall, the DBT group had a lower recall rate (9.1% versus 11.2%, p < 0.001) and higher cancer detection rate (6.0 vs 4.1, p < 0.001) compared to the FFDM group.     

Nationwide breast cancer screening programme fully implemented in The Netherlands

The period 1990-1997 saw the implementation of a nationwide breast cancer screening programme in the Netherlands, which provided biennial mammography for all women aged 50-69 years (50-75 years at present). The National Evaluation Team monitors the programme annually collecting regional data on screening outcomes; regional cancer registries provide data on interval cancers and on breast cancers in unscreened women by linkage of cancer registry data to data on screened women. Of 4 million women invited, 78.5% attended for screening. Screening resulted in 13.1 referrals, 9.2 biopsies and 6.1 breast cancers detected per 1000 women screened initially (6.9, 4.5 and 3.5 per 1000 in subsequently screened women, respectively). Within the first 2 years following screening 0.95 interval cancers per 1000 women-years were diagnosed. The stage distribution of screen-detected cancers was more favourable than that of interval cancers and of those diagnosed in unscreened women. The results are largely consistent with expectations. Results may nonetheless be further improved, particularly the detection rate in subsequent screens.     

Extent of prostate-specific antigen contamination in the Spanish section of the European Randomized Study of Screening for Prostate Cancer (ERSPC)

OBJECTIVES: The performance of tests outside prostate cancer screening trials (PSA contamination) may affect their statistical power. The present study addressed the extent of PSA contamination in the Spanish section of the European Randomized Study of Screening for Prostate Cancer (ERSPC) and its impact on biopsy performance and prostate cancer detection. METHODS: Data linkage was performed to address screening-related interventions outside the study. Four databases were used: (1) Spanish ERSPC database (n=4278), (2) laboratory database with all PSA determinations (n=31,140), (3) database of 1608 prostate biopsies, and (4) records of all prostate cancers (n=819) diagnosed at our centre. PSA contamination, biopsy performance, and cancer detection rates were calculated. RESULTS: Median follow-up time was 6.6 yr. A total of 2201 PSA determinations were performed for 1253 men. Cumulative PSA contamination was 29.3% (17% in the control arm during the first 4 yr). A higher proportion of men undergoing biopsies was found in the screening arm (21.3% vs. 2.9% in the control arm, p<0.0001). Similarly, higher cancer detection rates were found in the screening (4.7% vs. 1.2% in the control arm, p<0.0001). CONCLUSIONS: In our experience, the PSA contamination rate has increased during the last years, but its impact on biopsy performance and cancer detection in the control arm of the trial is limited and not likely to compromise the statistical power of the ERSPC trial.     

Breast Cancers Found with Digital Breast Tomosynthesis: A Comparison of Pathology and Histologic Grade

To compare the pathology and histologic grading of breast cancers detected with digital breast tomosynthesis to those found with conventional digital mammography. The institutional review board approved this study. A database search for all breast cancers diagnosed from June 2012 through December 2013 was performed. Imaging records for these cancers were reviewed and patients who had screening mammography with tomosynthesis as their initial examination were selected. Five dedicated breast imaging radiologists reviewed each of these screening mammograms to determine whether the cancer was visible on conventional digital mammography or whether tomosynthesis was needed to identify the cancer. A cancer was considered mammographically occult if all five radiologists agreed that the cancer could not be seen on conventional digital mammography. The size, pathology and histologic grading for all diagnosed breast cancers were then reviewed. The Mann–Whitney U and Fisher exact tests were utilized to determine any association between imaging findings and cancer size, pathologic type and histologic grade. Sixty‐five cancers in 63 patients were identified. Ten of these cancers were considered occult on conventional digital mammography and detected with the addition of tomosynthesis. These mammographically occult cancers were significantly associated with Nottingham grade 1 histologic pathology (p = 0.02), were smaller (median size: 6 mm versus 10 mm, p = 0.07) and none demonstrated axillary nodal metastases. Breast cancers identified through the addition of tomosynthesis are associated with Nottingham grade 1 histologic pathology and prognostically more favorable than cancers identified with conventional digital mammography alone.     

The demands of screening mammography on surgical inpatient services of breast cancer.

A nationwide mammographic screening of women ages 50 to 59 years commenced in Finland in January 1987. We studied the demands of screening on surgical inpatient services by comparing the treatment strategy, volume of breast biopsies, and hospital stay before and after implementation of mass screening of women age 50 to 59. Approximately 20 patients per 100,000 inhabitants were referred annually from mass screening for surgical biopsies, in half of which cancer was detected. In 1985 through 1986 (before screening) we operated on 134 patients suspected of having breast cancer. After the first (in 1990) and the second (in 1995) round of mammographic screening we operated on 161 patients in 2 years suspected of having breast cancer. Concurrently 25 of 92 cancers (27%) were found only because of the screening. Before the screening period clinical symptoms and palpable tumors were cause for referral to surgery in 84 per cent of the cases and abnormal mammography in only 16 per cent. During screening these ratios were 34 and 61 per cent, respectively. The number of T(is)-1 cancers (<2 cm) increased from 44 per cent before screening to 70 per cent during screening. In contrast the number of T2 cancers (2-4 cm) decreased from 40 to 20 per cent. The mammographic screening did not increase the hospital stay of patients. We conclude that the mammographic screening program of all women age 50 to 59 years increased the number of surgical biopsies in our hospital by only 30 per cent. Breast cancer was found at an earlier stage during screening. More than one-fourth of breast cancers are currently found through the mass screening program in Finland.     

Survival rates for breast cancers detected in a community service screening mammogram program

BACKGROUND: This single-institution long-term prospective study was performed in the setting of community service screening mammography to evaluate the association between the methods of breast cancer detection and survival rates. METHODS: From 1994 through 2001, data on 1237 patients with breast cancer were collected concurrent with definitive surgical treatment and entered into a comprehensive database. RESULTS: Mammography was the sole method of detection for 517 (44%) of 1179 Tis-T2 breast cancers. Fifty-seven percent of invasive cancers detectable by mammography alone were less than 1 cm in diameter. For 1049 patients with invasive cancers, the 5-year overall observed survival rates were 94% for 372 whose cancers were detectable by mammogram alone and 87% for 677 whose cancers were detectable by palpation (alone or in combination with mammography) (P = .0002). CONCLUSIONS: Most of the contribution to breast cancer mortality reduction is from the detection of small nonpalpable cancers, not from adjuvant therapy.     

Value of Mass Screening for Thyroid Cancer

p < 0.05). The incidence of nodal metastases in the mass-screening group (38%) was significantly lower than in the outpatient group (68%) ( p < 0.05). Thus mass screening seemed to find thyroid cancers in a relatively early stage. Mass screening for thyroid cancer was economic in this instance because it was performed together with screening for other cancers, such as breast cancer. Thyroid cancer screening required less than one additional minute per subject. The ultimate aim of mass screening is to reduce mortality. No improvement in prognosis from enforced mass screening for thyroid cancer was detected in this study. It cannot be demonstrated that there is sufficient value of mass screening for thyroid cancer to perform it independently despite early cancer detection.     

Breast ultrasound in 22,131 asymptomatic women with negative mammography

PurposeTo evaluate increment cancer detection rate generated by ultrasound (US).Materials and methodsUS only detected cancers were assessed for 22,131 self-referring asymptomatic women with negative mammography and subgroups by age, previous cancer, breast density. Invasive assessment and surgical biopsy rate were evaluated.ResultsThe overall US detection was 1.85 per thousand (41/22,131). In the subgroups it was: 1.95 per thousand (22/11,274) in women <50 years vs 1.75 per thousand (19/10,857) in women ≥50 years (p = 0.42), 5.49 per thousand (12/2183) in women with previous cancer vs 1.45 per thousand (29/19,948) in women without cancer history (p = 0.0004), 2.21 per thousand (22/9960) in dense breasts (p = 0.17) vs 1.56 per thousand (19/12,171) in fatty breasts. The US generated invasive assessment was 1.9% (422/22,131). The benign to malignant open surgical biopsy ratio was 0.17 (7/41).ConclusionAdding US to negative mammography allowed for substantial incremental cancer detection rate (1.85 per thousand), particularly at age <50years, in women with previous breast cancer and in dense breasts.     

The Connecticut Experiments Second Year: Ultrasound in the Screening of Women with Dense Breasts

To determine if the addition of screening breast ultrasound in women with mammographically normal but dense breasts improves breast cancer detection. The study utilized a retrospective chart review. Data collected included: (a) total number of screening mammograms; (b) total number of dense breast screening ultrasounds; (c) screening ultrasound Breast Imaging Reporting Data System (BI‐RADS) code results; (d) biopsy results; and (e) demographic data on women with malignant biopsies. Data were obtained from sites throughout Connecticut from November 1, 2010 to October 31, 2011. Data from 5 Connecticut radiology practices covering 10 sites were collected. Sites conducted a total of 57,417 screening mammograms and 10,282 dense breast screening ultrasounds. Of the screening ultrasounds, 87% (8,972/10,282) were BI‐RADS 1 or 2, 9% (875/10,282) were BI‐RADS 3, 4% (435/10,282) were BI‐RADS 4 or 5, and 39 were found to have a cancer or high‐risk lesion on biopsy. This correlates to 3.8 cancers or high‐risk lesions per 1,000 women screened. If high‐risk lesions are excluded, there are 24 cases of biopsy proven malignancy corresponding to 2.3 cancers per 1,000 women screened. In this study, screening breast ultrasound in women with mammographically normal but dense breasts demonstrated a positive predictive value of 9% (39/435) and specificity of 96% (8,972/9,368). Based on the data collected from sites throughout Connecticut, screening breast ultrasound in women with dense breast parenchyma detects mammographically occult malignancy and high‐risk lesions. The results are especially significant given recent studies suggesting that breast density is an independent risk factor for breast cancer and that mammography is less effective in detecting cancer in dense breasts. The improved specificity and sensitivity between the 1st and 2nd years’ suggests there is a learning curve that may continue to improve the results.     

The role of magnetic resonance imaging mammography in the surgical management of the index breast cancer

HYPOTHESIS: Preoperative magnetic resonance imaging (MRI) mammography, after positive fine-needle aspiration (FNA) or stereotactic biopsy, may alter surgical management of the index breast cancer. DESIGN: Review of MRI mammograms compared with conventional mammograms and clinical examination. SETTING: Rural community hospital. PATIENTS: Consecutive cohort of 27 patients with breast cancer who underwent prebiopsy or preoperative MRI mammography. INTERVENTION: Surgical management of breast cancer. MAIN OUTCOME MEASURE: Change in surgical management prompted by findings on MRI mammography. RESULTS: Prebiopsy or preoperative MRI mammography changed surgical management in 13 (48%) of 27 patients with breast cancer by discovering multicentric cancers or more extensive cancer. Of the 27 patients, 9 with positive FNA biopsy results of palpable masses underwent preoperative MRI; in 6 of the 9, ipsilateral multicentric cancers or more extensive cancer was discovered that necessitated mastectomy rather than breast conservation. Eighteen of the 27 patients had category 4/5 mammograms. Ten of these patients had stereotactic biopsies followed by MRI; 4 of the 10 had changes on the MRIs that required mastectomy rather than breast conservation. Eight of the 27 patients had MRI before stereotactic biopsy; 3 of the 8 had MRI abnormalities that required mastectomy. One patient had contralateral, multicentric cancers not seen on conventional mammography, necessitating bilateral mastectomies. CONCLUSIONS: We recommend that patients who desire breast conservation undergo MRI mammography before biopsy of a category 4/5 mammogram or immediately after a positive FNA biopsy result of a palpable mass.     

Imaging techniques in breast cancer

Imaging is the mainstay in breast cancer diagnosis, with mammography being the primary screening tool used to detect small/asymptomatic cancers. Symptomatic patients undergo triple assessment which includes a clinical assessment, imaging and, if indicated, an image-guided biopsy for histological diagnosis. We discuss current and emerging breast imaging techniques used in breast cancer care. These include mammography, digital breast tomosynthesis, ultrasound and magnetic resonance. We also discuss image-guided biopsy and miscellaneous image-guided interventions that influence the management of breast cancer care.     

Breast biopsy with needle localization: influence of age and mammographic feature on the rate of malignancy in 350 nonpalpable breast lesions

The purpose of this study was to determine the influence of mammographic feature and patient age on the rate of malignancy in nonpalpable breast lesions. During a 3-year period, 305 patients underwent biopsy after needle localization of 350 nonpalpable breast lesions. A total of 66 malignant breast tumors were found (biopsy yield rate, 19%): 23 carcinoma in situ, 43 infiltrating cancer. The biopsy yield rate in women younger than 50 years was 8% (12 of 153) and in women 50 years or older 27% (54 of 197; p less than 0.001). The biopsy yield rate varied with the mammographic feature in both groups of patients and was highest for spicular masses (61%), followed by strongly suspicious calcifications (29%). No cancers were found among well-defined masses or asymmetric densities. Other factors that were associated with high biopsy yield rate were personal or family history of breast cancer and diagnostic, rather than screening, mammography. The results suggest that the rate of malignancy in nonpalpable breast lesions is influenced by several factors, including age of patient and mammographic feature of the lesion. By taking all these factors into account, biopsies can possibly be performed more selectively thereby increasing the cost effectiveness of biopsy for occult breast cancer.     

Mammographic surveillance in women with a personal history of breast cancer: How accurate? How effective?

We review the accuracy and potential effect of mammography in surveillance of women with a personal history of breast cancer (PHBC). A literature review was performed to identify studies on screening mammography or breast surveillance reporting data on the accuracy or detection capability of mammography, or the effect of early detection of second breast cancers, in women with a PHBC. Evidence on mammography screening in women with PHBC comes from non-randomised studies, and is generally limited by several factors including design limitations. The proportion of ipsilateral breast recurrences detected with mammography ranges between 50% and 80% (including cancers detected also on clinical examination) but is lower at 8%–51% for mammography-only detection. Mammography detects approximately 45%–90% of contralateral cancers. There is evidence of a potential benefit for asymptomatic/early-detected second breast cancers (range of estimated hazard ratios: 0.10–0.86) relative to symptomatic or clinical-detection, in various surveillance strategies that include mammography, however these estimates are likely to have overestimated screening benefit. New evaluations of screening women with a PHBC are needed from screening programs or population datasets, to provide comprehensive measures of screening accuracy and outcomes in this population of women.