Computer-aided detection mammography for breast cancer screening: systematic review and meta-analysis

Context  Mammography is generally accepted as the best available breast cancer screening method; however, some cancers detectable on mammography images are missed. Computer-aided detection (CAD) systems for mammography are intended to reduce false negatives by marking suspicious areas of the mammograms for reviewers to consider. Although the prospect of improving the sensitivity of screening mammograms has led to the diffusion of CAD for mammography, little is known about its diagnostic accuracy. Objective  To assess the diagnostic performance of CAD for screening mammography in terms of sensitivity and specificity and incremental recall, biopsy, and cancer diagnosis rates. Data sources  Published literature identified by systematic literature searches of 17 databases, including MEDLINE, EMBASE, and the Cochrane Library, searched through 25 September 2008. Study selection  A reviewer and an information specialist selected full-length English-language articles that enrolled asymptomatic women for routine breast cancer screening and provided data needed for our analyses using criteria established a priori. We identified 75 potentially relevant publications, of which 7 (9%) were included. Data extraction  Data were extracted and internal validity was assessed by a single review author, and forms were approved by the co-authors. Results  Three studies (n = 347,324) reported sensitivity and specificity, or data to calculate them, and five studies (n = 51,162) reported data to calculate incremental rates of cancer diagnoses and recall and biopsy of women who did not have breast cancer. The pooled sensitivity was 86.0% (95% CI 84.2–87.6%) and specificity was 88.2% (95% CI 88.1–88.3%). Of the 100,000 women screened, CAD yielded an additional 50 (95% CI 30–80) correct breast cancer diagnoses, 1,190 (95% CI 1,090–1,290) recalls of healthy women, and 80 (95% CI 60–100) biopsies of healthy women. A total of 96% (95% CI 93.9–97.3%) of women recalled based upon CAD and 65.1% (95% CI 52.3–76.0%) of women biopsied based upon CAD were healthy. No studies reported patient-oriented clinical outcomes.     

Use of mammography in screening for breast cancer

Recognizing the enormous impact that quality breast screening mammography can have on reducing breast cancer deaths, we need to determine when women's and physician's perceived restrictions for mammography examination impede the progress of its use for early cancer detection. A uniform system should emphasize valid communication and education between women and their physicians. Women seek to have a voice in their medical treatment. Yet that responsibility has an emotional price. Physicians and patients must decide together on the most appropriate strategies to enhance communication and adopt specific guidelines they will adhere to, to detect and cure early breast cancer. Women must be educated about breast screening mammography, and physicians must increase their efforts to proclaim its importance. Women need be assured the trend is toward using the most modern mammographic techniques. Quality medical care is medicine's purpose and in women's best interest. At present, no other diagnostic method is equivalent to mammography and capable of providing an equivalent impact on improving the detection and cure rate of breast cancer. Despite medical activities designed to reduce uncertainty in medicine, scientific evidence has not provided systematic answers as to the "best" way to approach issues of quality, cost, accessibility, or communication for breast screening mammography. No particular expert opinion or preference prevails for breast screening protocols. What is needed is adoption of a multidisciplinary approach, educating and motivating women and physicians to participate in breast screening activities. With trends directed toward high-volume breast screening operations, low-cost, quality mammography must be available and be impeccably performed. Some activities are natural subjects for financial quantification. It is objectionable to assume, however, that we can accurately place and agree on dollar amounts alone to represent the costs and benefits of screening mammography. The gaps between practices and attitudes about the benefits, risks, and costs of screening mammography suggest that people are not satisfied with the way physicians, women, influential groups, or regulatory agencies are balancing all of the elements. Better communication must exist between physicians and their peer groups involved in performing responsible mammography. Better communication must be achieved between physicians and women to take advantage of the usefulness of quality breast screening mammography. High-quality screening programs must be linked to third-party reimbursement and to legislation, if we are to make a difference. Screening mammography deserves our medical, economic, social, and political attention and action.     

Cervicography as an adjunctive test to visual inspection with acetic acid in cervical cancer detection screening.

OBJECTIVE: Validate Digital Cervicography as adjunctive cervical cancer screening test to VIA and Cytology. METHOD: Women (1292) were submitted to both cytological and VIA tests to obtain a sample of 301 positive VIA cases (23.3%) which have had the Digital Cervicography (DC) taken and evaluated. Just cases considered positive by DC (149/301 cases--49.5%) and/or positive Pap smear tests were referred to colposcopy and biopsy whenever indicated. RESULTS: Cervical smear was positive in 5.4%, including LGSIL (4%), HGSIL (1%) and one case of invasive cancer (0.4%), and 1.6% of ASCUS or AGUS). DC identified 81 positive cases (74 LGSIL; 5 HGSIL; 2 cancers). The sensitivity of cytology was 14.8%, and the DC was 100%. Corresponding specificities were 95.4% and 69.1%, respectively. The NPV and PPV for DC were 100% and 54.4%. CONCLUSION: DC increases sensitivity, specificity and positive predictive value of VIA, becoming a valid adjunctive screening test for cervical cancer in low resource settings.     

X-ray mammography and diaphanography in screening for breast cancer

Modern low-dose dedicated x-ray mammography has been demonstrated in large clinical trials to have high efficacy in the detection of occult breast malignancy. Such early detection results in decreased fatality rates. A theoretical risk of breast cancer induced from diagnostic ionizing radiation has not been proven for the low doses now used in mammographic techniques. High accuracy can be achieved in the mammographic evaluation of breast lesions. In contrast, nonionizing transillumination of the breast, or diaphanography, remains an investigational approach to the evaluation of breast disease and warrants further controlled study before its widespread clinical application.     

Adoption of HPV testing as an adjunct to conventional cytology in cervical cancer screening in Japan

Objective

To assess the effectiveness of including HPV testing as an adjunct to conventional cytology in cervical cancer screening.

Methods

Atypical epithelial cells (ATC) were classified according to the 2001 Bethesda classification system. The study ran for 6 years from May 2004 to November 2009 in conjunction with public cervical cancer screening for Kanazawa City residents. Patients with ATC (ASC-US, ASC-H, and AGC) underwent parallel testing for high-risk HPV types with the Hybrid Capture II system; HPV positive and cytology-ATC cases were recalled for colposcopic examination and biopsied if necessary. Results were compared with those obtained before HPV screening was initiated.

Results

A total of 62 645 women underwent screening over the 6-year period; of these, 3622 (5.8%) were ATC positive, among whom 527 (14.5%) tested HPV-positive. These 527 women (0.8% of the screened population) were recalled for colposcopic examination. The resulting 426 biopsies were diagnosed as CIN 1 (n = 187), CIN 2 (n = 53), CIN 3 (n = 11), and invasive cervical cancer (n = 2).

Conclusion

HPV testing as an adjunct to conventional cytology in cervical cancer screening seems to increase detection sensitivity with proven cost-effectiveness.     

Primary radiation therapy as an alternative to mastectomy for early-stage breast cancer

Breast conservation surgery followed by radiation therapy for definitive treatment of patients with early stage (limited extent) breast cancer (Stage I and Stage II) has been reported by several retrospective and prospective randomized trials to provide comparable local control, disease-free survival, and overall survival to patients treated with mastectomy. Excisional biopsy of the breast lump and associated axillary dissection are required prior to initiation of radiation therapy in order to remove all known tumor and to reduce the dose of radiation required for cure. The axillary dissection is therapeutic for extension into the axillary volume as well as a prognosticator that aids in the selection of patients for adjuvant systemic therapy. Although certain patients may be adequately served without radiation therapy by excisional removal of the tumor and a margin of surrounding normal breast tissue, this population still needs to be defined. Adequate patient selection and the use of good surgical and radiation therapy techniques results in good to excellent cosmesis in 80 to 90 per cent of treated patients. The treatment alternatives, if presented to patients deemed as appropriate candidates, will aid the patients in making an informed consent decision. Wider application and availability of this alternative to mastectomy may have a significant positive impact on our female population by encouraging women to seek detection of breast cancer through breast self-examination and mammography because the desirable alternative reduces the fear of loss of the breast and self image.     

Cardiac tamponade as an unusual presentation of advanced breast cancer in pregnancy

BACKGROUND: Breast cancer is the most commonly diagnosed cancer in pregnancy. Though the prognosis by stage is not different from that in nonpregnant women, it is more likely to present at an advanced stage in pregnancy. CASE: A 28-year-old primigravida presented with dyspnea and pleuritic chest pain. The workup revealed cardiac tamponade. Pericardiocentesis and subsequent pericardial window were performed. Cytology of the pericardial fluid revealed poorly differentiated adenocarcinoma. Ultrasonography displayed a right breast mass, and biopsy identified it as the primary source of the cancer. CONCLUSION: Cardiac tamponade is an unusual presentation of advanced breast cancer. To the best of our knowledge, it has not previously been described as occurring in pregnancy.     

Sentinel node detection applied to breast cancer: 2007 update

The technique of detection and resection of the sentinel lymph node applied to early breast cancer management aims to spare the patient with a low risk of lymph node involvement an unnecessary axillary lymphadenectomy. This innovating technique lies on the double hypothesis of an accuracy to predict non sentinel lymph node status and to induce a lower morbidity when compared with axillary lymphadenectomy. This multidisciplinary technique depends on surgeons, nuclear physicians and pathologists. In practice sentinel lymph nodes are detected thanks to two types of tracers, the Blue and the colloids marked with technetium, harvested by the surgeon guided by the blue lymphatic channel and the use of a gamma probe detection, analyzed by the pathologist according to a particular procedure with the concept of serial slices, and possibly immuno histo chemistry. The objectives of this review are to specify the state of knowledge concerning the different steps: detection, surgical resection and the pathological analysis of the sentinels lymph nodes and to focus on validated and controversial indications, and on the main ongoing trials.     

Early detection of breast cancer in the emerging world

Breast cancer is the number one cancer of women in the world. In middle income countries, and in many low income countries, breast cancer has become the most frequent cancer in women, supplanting cancer of the cervix. In such countries, breast cancer is usually diagnosed at an advanced stage, the majority in stage III and IV, indicating substantial delay in diagnosis. Further, because of the age distribution of the population pyramid, the majority of breast cancers are diagnosed in women under the age of 50. However, that age distribution does not mean that breast cancer is a different disease than in the West. Where population-based cancer registry data are available, it becomes clear that the individual risk for women at every age is no greater than in the West, and in many countries much less.     

Breast cancer detection: age-related significance of findings on physical exam and mammography

Data of 909 consecutive patients who underwent physical exam (PE), mammography (MG), and breast biopsy were analyzed in a retrospective study. Preoperative findings of PE and MG were classified as (1) suspicious for malignancy, (2) probably benign lesion, (3) normal and correlated with histology of the biopsy and the patient's age. Sensitivity of PE remained on a 0.9 level approximately up to age 50 and dropped to 0.78 and 0.85 respectively thereafter. Sensitivity of MG was slightly lower and was 0 in the age group 30 years and younger. Specificity of PE rose from 0.52 to 0.84 and dropped to 0.55 in women above 70 years. Specificity of MG decreased from 0.9 to 0.4 over the age groups. The relatively low positive predictive value of both PE and MG--particularly in the lower age groups--leads to an excessive rate of benign biopsies up to the age of 60. Due to suboptimal sensitivity PE and MG have to be used as a combined diagnostic modality if a reduction of breast cancer mortality is to be accomplished. Screening programs are of particular efficacy in women over 45 years of age due to age-dependent incidence figures and diagnostic sensitivity of PE and MG in this age group.