Factors Associated With Rates of False-Positive and False-Negative Results From Digital Mammography Screening: An Analysis of Registry Data

Multiclass Segmentation of Suspicious Findings in Simulated Breast Tomosynthesis Images Using a U-Net

Our lab has built a next-generation tomosynthesis (NGT) system utilizing scanning motions with more degrees of freedom than clinical digital breast tomosynthesis systems. We are working toward designing scanning motions that are customized around the locations of suspicious findings. The first step in this direction is to demonstrate that these findings can be detected with a single projection image, which can guide the remainder of the scan. This paper develops an automated method to identify findings that are prone to be masked. Perlin-noise phantoms and synthetic lesions were used to simulate masked cancers. NGT projections of phantoms were simulated using ray-tracing software. The risk of masking cancers was mapped using the ground-truth labels of phantoms. The phantom labels were used to denote regions of low and high risk of masking suspicious findings. A U-Net model was trained for multiclass segmentation of phantom images. Model performance was quantified with a receiver operating characteristic (ROC) curve using area under the curve (AUC). The ROC operating point was defined to be the point closest to the upper left corner of ROC space. The output predictions showed an accurate segmentation of tissue predominantly adipose (mean AUC of 0.93). The predictions also indicate regions of suspicious findings; for the highest risk class, mean AUC was 0.89, with a true positive rate of 0.80 and a true negative rate of 0.83 at the operating point. In summary, this paper demonstrates with virtual phantoms that a single projection can indeed be used to identify suspicious findings.

Can multi-parametric magnetic resonance imaging and prostate-specific antigen density accurately stratify patients prior to prostate biopsy?

Objective:

This study examines the diagnostic accuracy of multi-parametric magnetic resonance imaging (mpMRI) in a high-volume centre to potentially stratify patients prior to prostate biopsy.

Methods:

All biopsy naïve patients who had mpMRI prostate and transperineal biopsy of prostate (TPBx) in 2017 and 2018 were included. There were no exclusion criteria. All patients, regardless of the mpMRI result, underwent systematic template biopsy under general anaesthesia with cognitive target biopsy if indicated. Clinicopathological data were extracted from medical records. The primary outcome was the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of mpMRI prostate in the detection of prostate cancer (PCa) compared with template TPBx.

Results:

In total, 140 patients were included. Overall, 57.1% had a positive biopsy. A higher Prostate Imaging-Reporting and Data Systems (PI-RADS) score was associated with a higher risk of diagnosing clinically significant PCa (International Society of Urological Pathology (ISUP) ⩾ 2) ( p < 0.001). The sensitivity, specificity, NPV, and PPV of mpMRI in detecting clinically significant PCa with a PI-RADS ⩾ 3 lesion, was 95% (95% confidence interval (CI) 83.0–99.3%), 41% (95% CI 31.3–51.3%), 95.3% (95% CI 84.2–99.4%) and 39.2% (95% CI 29.4–49.6%), respectively. Combining this with prostate-specific antigen density (PSAD) of <0.15 further improved the NPV to 100% (86.3–100). Binomial logistic regression to understand the effects of PSA, DRE and PI-RADS score on predicting clinically significant PCa (ISUP ⩾ 2) found increasing PSA (odds ratio (OR) 1.06, (95% CI 1.00–1.11, p = 0.022)) and PI-RADS (OR 3.17, (95% CI 1.94–5.18, p < 0.001)) to be significant predictors. Malignant DRE was not a significant predictor ( p = 0.087).

Conclusion:

This study demonstrates that the high sensitivity and NPV of mpMRI combined with PSAD may play a pivotal role in stratifying men for prostate biopsy and help avoid biopsy and its associated morbidity in select patients.

Level of Evidence:

2b (Oxford Centre for Evidence-Based Medicine: Levels of Evidence)

Prevalence and correlates of false-positive results after 3-D screening mammography among uninsured women in a community outreach program

False-positive results have been rarely investigated among uninsured minority women who undergo 3-D screening mammography. Here, we analyzed data from 21,022 women participating in the Breast Screening and Patient Navigation (BSPAN) program of North Texas with an aim to report prevalence and correlates of false-positive results after 3-D screening mammography, stratified by age. False-positives were defined as a negative diagnostic mammogram or a negative biopsy within 1 year of a positive screen. We used multivariable logistic regression to assess associations of demographic and clinical covariates and false positive results for age groups 40–49 and 50–64 years. Prevalence of false-positive results was 11.8% and 9.6% in the 40–49 and 50–64 age groups, respectively. Multivariable logistic regression demonstrated that, in the 40–49 age group, women who were non-menopausal, did not use hormone replacement therapy (HRT), and had self-reported prior mammograms had higher odds of false-positive results than those who were menopausal, used HRT and had no self-reported prior mammograms, respectively. In the 50–64 age group, women with a prior self-reported diagnostic mammogram had higher odds of false-positive results than those without a prior self-reported diagnostic mammogram. This study establishes contemporary evidence regarding prevalence and correlates of false-positive results after 3-D mammography in the unique BSPAN population, and demonstrate that use of 3-D mammography is not enough to reduce false-positive rates among uninsured women served through community outreach programs. Further research is needed to explore improved techniques to reduce false-positive rates, and ensure optimal use of scarce resources in outreach programs.

Cumulative Probability of False-Positive Results After 10 Years of Screening With Digital Breast Tomosynthesis vs Digital Mammography

Importance

Breast cancer screening with digital breast tomosynthesis may decrease false-positive results compared with digital mammography.

Objective

To estimate the probability of receiving at least 1 false-positive result after 10 years of screening with digital breast tomosynthesis vs digital mammography in the US.

Design, Setting, and Participants

An observational comparative effectiveness study with data collected prospectively for screening examinations was performed between January 1, 2005, and December 31, 2018, at 126 radiology facilities in the Breast Cancer Surveillance Consortium. Analysis included 903 495 individuals aged 40 to 79 years. Data analysis was conducted from February 9 to September 7, 2021.

Exposures

Screening modality, screening interval, age, and Breast Imaging Reporting and Data System breast density.

Main Outcomes and Measures

Cumulative risk of at least 1 false-positive recall for further imaging, short-interval follow-up recommendation, and biopsy recommendation after 10 years of annual or biennial screening with digital breast tomosynthesis vs digital mammography, accounting for competing risks of breast cancer diagnosis and death.

Results

In this study of 903 495 women, 2 969 055 nonbaseline screening examinations were performed with interpretation by 699 radiologists. Mean (SD) age of the women at the time of the screening examinations was 57.6 (9.9) years, and 58% of the examinations were in individuals younger than 60 years and 46% were performed in women with dense breasts. A total of 15% of examinations used tomosynthesis. For annual screening, the 10-year cumulative probability of at least 1 false-positive result was significantly lower with tomosynthesis vs digital mammography for all outcomes: 49.6% vs 56.3% (difference, -6.7; 95% CI, -7.4 to -6.1) for recall, 16.6% vs 17.8% (difference, -1.1; 95% CI, -1.7 to -0.6) for short-interval follow-up recommendation, and 11.2% vs 11.7% (difference, -0.5; 95% CI, -1.0 to -0.1) for biopsy recommendation. For biennial screening, the cumulative probability of a false-positive recall was significantly lower for tomosynthesis vs digital mammography (35.7% vs 38.1%; difference, -2.4; 95% CI, -3.4 to -1.5), but cumulative probabilities did not differ significantly by modality for short-interval follow-up recommendation (10.3% vs 10.5%; difference, -0.1; 95% CI, -0.7 to 0.5) or biopsy recommendation (6.6% vs 6.7%; difference, -0.1; 95% CI, -0.5 to 0.4). Decreases in cumulative probabilities of false-positive results with tomosynthesis vs digital mammography were largest for annual screening in women with nondense breasts (differences for recall, -6.5 to -12.8; short-interval follow-up, 0.1 to -5.2; and biopsy recommendation, -0.5 to -3.1). Regardless of modality, cumulative probabilities of false-positive results were substantially lower for biennial vs annual screening (overall recall, 35.7 to 38.1 vs 49.6 to 56.3; short-interval follow-up, 10.3 to 10.5 vs 16.6 to 17.8; and biopsy recommendation, 6.6 to 6.7 vs 11.2 to 11.7); older vs younger age groups (eg, among annual screening in women ages 70-79 vs 40-49, recall, 39.8 to 47.0 vs 60.8 to 68.0; short-interval follow-up, 13.3 to 14.2 vs 20.7 to 20.9; and biopsy recommendation, 9.1 to 9.3 vs 13.2 to 13.4); and women with entirely fatty vs extremely dense breasts (eg, among annual screening in women aged 50-59 years, recall, 29.1 to 36.3 vs 58.8 to 60.4; short-interval follow-up, 8.9 to 11.6 vs 19.5 to 19.8; and biopsy recommendation, 4.9 to 8.0 vs 15.1 to 15.3).

Conclusions and Relevance

In this comparative effectiveness study, 10-year cumulative probabilities of false-positive results were lower on digital breast tomosynthesis vs digital mammography. Biennial screening interval, older age, and nondense breasts were associated with larger reductions in false-positive probabilities than screening modality.

Breast biopsy patterns and findings among older women undergoing screening mammography: The role of age and comorbidity

INTRODUCTION

Limited evidence exists on the impact of age and comorbidity on biopsy rates and findings among older women.

MATERIALS AND METHODS

We used data from 170,657 women ages 66-94 enrolled in the United States Breast Cancer Surveillance Consortium (BCSC). We estimated one-year rates of biopsy by type (any, fine-needle aspiration (FNA), core or surgical) and yield of the most invasive biopsy finding (benign, ductal carcinoma in situ (DCIS) and invasive breast cancer) by age and comorbidity. Statistical significance was assessed using Wald statistics comparing coefficients estimated from logistic regression models adjusted for age, comorbidity, BCSC registry, and interaction between age and comorbidity.

RESULTS

Of 524,860 screening mammograms, 9830 biopsies were performed following 7930 exams (1.5%) within one year, specifically 5589 core biopsies (1.1%), 3422 (0.7%) surgical biopsies and 819 FNAs (0.2%). Biopsy rates per 1000 screens decreased with age (66-74:15.7, 95%CI:14.8-16.8), 75-84:14.5(13.5-15.6), 85-94:13.2(11.3,15.4), p_trend < 0.001) and increased with Charlson Comorbidity Score (CCS = 0:14.4 (13.5-15.3), CCS = 1:16.6 (15.2-18.1), CCS ≥2:19.0 (16.9-21.5), p_trend < 0.001).Biopsy rates increased with CCS at ages 66-74 and 75-84 but not 85-94. Core and surgical biopsy rates increased with CCS at ages 66-74 only. For each biopsy type, the yield of invasive breast cancer increased with age irrespective of comorbidity.

DISCUSSION

Women aged 66-84 with significant comorbidity in a breast cancer screening population had higher breast biopsy rates and similar rates of invasive breast cancer diagnosis than their counterparts with lower comorbidity. A considerable proportion of these diagnoses may represent overdiagnoses, given the high competing risk of death from non-breast-cancer causes among older women.

Development and validation of a circulating microRNA panel for the early detection of breast cancer

BACKGROUND

Mammography is widely used for breast cancer screening but suffers from a high false-positive rate. Here, we perform the largest comprehensive, multi-center study to date involving diverse ethnic groups, for the identification of circulating miRNAs for breast cancer screening.

METHODS

This study had a discovery phase (n = 289) and two validation phases (n = 374 and n = 379). Quantitative PCR profiling of 324 miRNAs was performed on serum samples from breast cancer (all stages) and healthy subjects to identify miRNA biomarkers. Two-fold cross-validation was used for building and optimising breast cancer-associated miRNA panels. An optimal panel was validated in cohorts with Caucasian and Asian samples. Diagnostic ability was evaluated using area under the curve (AUC) analysis.

RESULTS

The study identified and validated 30 miRNAs dysregulated in breast cancer. An optimised eight-miRNA panel showed consistent performance in all cohorts and was successfully validated with AUC, accuracy, sensitivity, and specificity of 0.915, 82.3%, 72.2% and 91.5%, respectively. The prediction model detected breast cancer in both Caucasian and Asian populations with AUCs ranging from 0.880 to 0.973, including pre-malignant lesions (stage 0; AUC of 0.831) and early-stage (stages I-II) cancers (AUC of 0.916).

CONCLUSIONS

Our panel can potentially be used for breast cancer screening, in conjunction with mammography.

The psychological impact of esophageal cancer screening on anxiety and depression in China

OBJECTIVE

The psychological impact of screening is unclear and has been ignored. This study aimed to evaluate the psychological impact of esophageal cancer (EC) screening on anxiety and depression in China.

MATERIALS AND METHODS

A multicenter, population-based study in five high-risk regions of EC was conducted from 2019 to 2020. Residents were recruited and underwent endoscopic screening and then were diagnosed with normal, esophagitis, low-grade intraepithelial neoplasia (LGIN), high-grade intraepithelial neoplasia (HGIN) and EC. Subjects who did not participate in the screening were referred to as the control group. We surveyed their anxiety and depression levels at baseline and after endoscopy and informed them of different pathological results to evaluate the psychological impact of the screening process.

RESULTS

A total of 2,337 subjects completed all surveys in the screening process (normal: 355, esophagitis: 1,713, LGIN: 213, HGIN: 43 and EC: 13), with 63 controls. The levels of anxiety and depression of screeners were significantly higher than those of controls (P < 0.001). The fluctuation of anxiety and depression showed a "V" pattern in the screening process. The prevalence of anxiety symptoms at baseline, after endoscopy and after knowing the pathological results was 5.6, 0.3, and 3.2%, respectively (P < 0.001), and the corresponding prevalence of depression was 3.6, 0.2, and 2.1%, respectively (P < 0.001). With the aggravation of pathological results, the levels of anxiety and depression increased significantly (P < 0.001), especially in patients informed of HGIN (16.3 and 9.3%) and EC (23.1 and 30.8%).

CONCLUSION

Participation in endoscopic screening may bring short-term adverse psychological effects, especially at baseline and knowing the pathological results. More attention should be given to participants waiting for endoscopic screening. The method of informing the screening results of HGIN and EC should be improved. Further precise screening is needed to concentrate on high-risk groups to reduce the psychological impact of screening.

Cost-effectiveness of abbreviated-protocol MRI screening for women with mammographically dense breasts in a national breast cancer screening program

Introduction

Magnetic resonance imaging (MRI) has shown the potential to improve the screening effectiveness among women with dense breasts. The introduction of fast abbreviated protocols (AP) makes MRI more feasible to be used in a general population. We aimed to investigate the cost-effectiveness of AP-MRI in women with dense breasts (heterogeneously/extremely dense) in a population-based screening program.

Methods

A previously validated model (SiMRiSc) was applied, with parameters updated for women with dense breasts. Breast density was assumed to decrease with increased age. The base scenarios included six biennial AP-MRI strategies, with biennial mammography from age 50–74 as reference. Fourteen alternative scenarios were performed by varying screening interval (triennial and quadrennial) and by applying a combined strategy of mammography and AP-MRI. A 3% discount rate for both costs and life years gained (LYG) was applied. Model robustness was evaluated using univariate and probabilistic sensitivity analyses.

Results

The six biennial AP-MRI strategies ranged from 132 to 562 LYG per 10,000 women, where more frequent application of AP-MRI was related to higher LYG. The optimal strategy was biennial AP-MRI screening from age 50–65 for only women with extremely dense breasts, producing an incremental cost-effectiveness ratio of € 18,201/LYG. At a threshold of € 20,000/LYG, the probability that the optimal strategy was cost-effective was 79%.

Conclusion

Population-based biennial breast cancer screening with AP-MRI from age 50–65 for women with extremely dense breasts might be a cost-effective alternative to mammography, but is not an option for women with heterogeneously dense breasts.

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AP-MRI can be cost-effective for screening women with extremely dense breast.

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The more frequent the use of AP-MRI, the more life years will be gained.

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Biennial AP-MRI for women with extremely dense breast up to age 65 is optimal.

Public health radiography: A scoping review of benefits, and growth opportunities for radiographers

INTRODUCTION

There is growing adoption of radiographic techniques in public health to improve outcomes of chronic and communicable diseases. This review examines the applications, benefits, and implications of radiography in public health. It also examines the challenges and potential advanced practice roles for radiographers in public health radiography (PHR).

METHODOLOGY

Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Scoping review extension (PRISMA- ScR) checklist was employed, and the search was conducted using PubMed, Medline, Web of Science, ScienceDirect, and Google Scholar to identify relevant articles that explored the concept of radiography in public health. Evidence was analysed using an inductive iterative approach.

RESULTS

Radiographic imaging modalities such as ultrasound, computed tomography, and plain X-ray had wide applicability in public health fields of preventive cardiology, preventive oncology, maternal health, infectious disease epidemiology, and radiographic informatics. PHR effectively reduced mortality, improved outcomes, informed lifestyle changes to mitigate the risk of impending disease. PHR also helped in monitoring disease progression and predicting treatment outcomes. However, evidence establishing a competency framework that supports PHR is scarce.

CONCLUSION

Radiography makes a significant contribution to public health in reducing mortality and morbidity. Therefore, developing a PHR competency framework can accentuate the contribution Radiographers make to solving public health issues.

Clinical Artificial Intelligence Applications: Breast Imaging

This article gives a brief overview of the development of artificial intelligence in clinical breast imaging. For multiple decades, artificial intelligence (AI) methods have been developed and translated for breast imaging tasks such as detection, diagnosis, and assessing response to therapy. As imaging modalities arise to support breast cancer screening programs and diagnostic examinations, including full-field digital mammography, breast tomosynthesis, ultrasound, and MRI, AI techniques parallel the efforts with more complex algorithms, faster computers, and larger data sets. AI methods include human-engineered radiomics algorithms and deep learning methods. Examples of these AI-supported clinical tasks are given along with commentary on the future.

Deep Vision for Breast Cancer Classification and Segmentation

Simple Summary

Breast cancer misdiagnoses increase individual and system stressors as well as costs and result in increased morbidity and mortality. Digital mammography studies are typically about 80% sensitive and 90% specific. Improvement in classification of breast cancer imagery is possible using deep vision methods, and these methods may be further used to identify autonomously regions of interest most closely associated with anomalies to support clinician analysis. This research explores deep vision techniques for improving mammography classification and for identifying associated regions of interest. The findings from this research contribute to the future of automated assistive diagnoses of breast cancer and the isolation of regions of interest.

Abstract

(1) Background: Female breast cancer diagnoses odds have increased from 11:1 in 1975 to 8:1 today. Mammography false positive rates (FPR) are associated with overdiagnoses and overtreatment, while false negative rates (FNR) increase morbidity and mortality. (2) Methods: Deep vision supervised learning classifies 299 × 299 pixel de-noised mammography images as negative or non-negative using models built on 55,890 pre-processed training images and applied to 15,364 unseen test images. A small image representation from the fitted training model is returned to evaluate the portion of the loss function gradient with respect to the image that maximizes the classification probability. This gradient is then re-mapped back to the original images, highlighting the areas of the original image that are most influential for classification (perhaps masses or boundary areas). (3) Results: initial classification results were 97% accurate, 99% specific, and 83% sensitive. Gradient techniques for unsupervised region of interest mapping identified areas most associated with the classification results clearly on positive mammograms and might be used to support clinician analysis. (4) Conclusions: deep vision techniques hold promise for addressing the overdiagnoses and treatment, underdiagnoses, and automated region of interest identification on mammography.

Serial dependence in the perceptual judgments of radiologists

In radiological screening, clinicians scan myriads of radiographs with the intent of recognizing and differentiating lesions. Even though they are trained experts, radiologists’ human search engines are not perfect: average daily error rates are estimated around 3–5%. A main underlying assumption in radiological screening is that visual search on a current radiograph occurs independently of previously seen radiographs. However, recent studies have shown that human perception is biased by previously seen stimuli; the bias in our visual system to misperceive current stimuli towards previous stimuli is called serial dependence. Here, we tested whether serial dependence impacts radiologists’ recognition of simulated lesions embedded in actual radiographs. We found that serial dependence affected radiologists’ recognition of simulated lesions; perception on an average trial was pulled 13% toward the 1-back stimulus. Simulated lesions were perceived as biased towards the those seen in the previous 1 or 2 radiographs. Similar results were found when testing lesion recognition in a group of untrained observers. Taken together, these results suggest that perceptual judgements of radiologists are affected by previous visual experience, and thus some of the diagnostic errors exhibited by radiologists may be caused by serial dependence from previously seen radiographs.

Epigenetically inactivated RASSF1A as a tumor biomarker

RASSF1A, one of the eight isoforms of the RASSF1 gene, is a tumor suppressor gene that influences tumor initiation and development. In cancer, RASSF1A is frequently inactivated by mutations, loss of heterozygosity, and, most commonly, by promoter hypermethylation. Epigenetic inactivation of RASSF1A was detected in various cancer types and led to significant interest; current research on RASSF1A promoter methylation focuses on its roles as an epigenetic tumor biomarker. Typically, researchers analyzed genomic DNA (gDNA) to measure the amount of RASSF1A promoter methylation. Cell-free DNA (cfDNA) from liquid biopsies is a recent development showing promise as an early cancer diagnostic tool using biomarkers, such as RASSF1A. This review discusses the evidence on aberrantly methylated RASSF1A in gDNA and cfDNA from different cancer types and its utility for early cancer diagnosis, prognosis, and surveillance. We compared methylation frequencies of RASSF1A in gDNA and cfDNA in various cancer types. The weaknesses and strengths of these analyses are discussed. In conclusion, although the importance of RASSSF1A methylation to cancer has been established and is included in several diagnostic panels, its diagnostic utility is still experimental.

Breast Cancer Information Behaviours and Needs among Singapore Women: A Qualitative Study

Background:

There is growing evidence on cancer communication and its impact on cancer-related health outcomes; however, little is known about how women gain access to and use breast cancer information in the multi-ethnic Asian context. This paper aimed to explore the breast cancer information acquisition behaviours and needs among Singapore women who attended a community-based health organisation for mammography screening.

Methods, design and setting:

Qualitative data were collected through semi-structured interviews with 37 racially diverse, aged 50 and above women, who have received mammography screening within the past two years. The interviews were conducted at either the Singapore Cancer Society Clinic or participant’s home.

Results:

Although cancer information scanning was more prevalent than information seeking (91.9% vs. 62.2%), those who purposively seek information exhibited a higher knowledge level of breast cancer. The most commonly cited sources for information scanning were friends, television and family, and for information seeking were the Internet, pamphlets from a healthcare organisation/ public authority, and healthcare providers. Singapore women were well-informed about the benefits of mammogram; however, specific knowledge, such as modifiable risk factors, reasons for different screening options and the trade-off between harm and benefit, was still lacking which led to confusion about screening.

Conclusion:

Breast cancer health educational materials should provide clear and balanced information to give women a more accurate or realistic expectation about mammography screening. Study findings provide important implications for breast cancer education and programs to move beyond simply raising awareness and craft specific informative messages addressing the needs of the target group.

A Review of Applications of Machine Learning in Mammography and Future Challenges

BACKGROUND

The aim of this study is to systematically review the literature to summarize the evidence surrounding the clinical utility of artificial intelligence (AI) in the field of mammography. Databases from PubMed, IEEE Xplore, and Scopus were searched for relevant literature. Studies evaluating AI models in the context of prediction and diagnosis of breast malignancies that also reported conventional performance metrics were deemed suitable for inclusion. From 90 unique citations, 21 studies were considered suitable for our examination. Data was not pooled due to heterogeneity in study evaluation methods.

SUMMARY

Three studies showed the applicability of AI in reducing workload. Six studies demonstrated that AI can aid in diagnosis, with up to 69% reduction in false positives and an increase in sensitivity ranging from 84 to 91%. Five studies show how AI models can independently mark and classify suspicious findings on conventional scans, with abilities comparable with radiologists. Seven studies examined AI predictive potential for breast cancer and risk score calculation. Key Messages: Despite limitations in the current evidence base and technical obstacles, this review suggests AI has marked potential for extensive use in mammography. Additional works, including large-scale prospective studies, are warranted to elucidate the clinical utility of AI.

Can supplementary contrast-enhanced MRI of the breast avoid needle biopsies in suspicious microcalcifications seen on mammography? A systematic review and meta-analysis

Purpose

To analyze the rate of potentially avoidable needle biopsies in mammographically suspicious calcifications if supplementary Contrast-Enhanced MRI (CE-MRI) is negative.

Methods

Using predefined criteria, a systematic review was performed. Studies investigating the use of supplemental CE-MRI in the setting of mammographically suspicious calcifications undergoing stereotactic biopsy and published between 2000 and 2020 were eligible. Two reviewers extracted study characteristics and true positives (TP), false positives, true negatives and false negatives (FN). Specificity, in this setting equaling the number of avoidable biopsies and FN rates were calculated. The maximum pre-test probability at which post-test probabilities of a negative CE-MRI met with BI-RADS benchmarks was determined by a Fagan nomogram. Random-effects models, I²-statistics, Deek’s funnel plot testing and meta-regression were employed. P-values <0.05 were considered significant.

Results

Thirteen studies investigating 1414 lesions with a cancer prevalence of 43.6% (range: 22.7–66.9%) were included. No publication bias was found (P = 0.91). CE-MRI performed better in pure microcalcification studies compared to those also including associate findings (P < 0.001). In the first group, the pooled rate of avoidable biopsies was 80.6% (95%-CI: 64.6–90.5%) while the overall and invasive cancer FN rates were 3.7% (95%-CI: 1.2–6.2%) and 1.6% (95%-CI 0–3.6%), respectively. Up to a pre-test probability of 22%, the post-test probability did not exceed 2%.

Conclusion

A negative supplementary CE-MRI could potentially avoid 80.6% of unnecessary stereotactic biopsies in BI-RADS 4 microcalcifications at a cost of 3.7% missed breast cancers, 1.6% invasive. BI-RADS benchmarks for downgrading mammographic calcifications would be met up to a pretest probability of 22%.

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A negative breast MRI can downgrade up to 80.6% of suspicious microcalcifications, potentially avoiding vacuum-assisted breast biopsies.

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Up to a pretest probability of 22% , a negative breast MRI result would not exceed the 2% cancer rate required for a BI-RADS 3 category assignment.

Applying a Random Projection Algorithm to Optimize Machine Learning Model for Breast Lesion Classification

OBJECTIVE

Since computer-aided diagnosis (CAD) schemes of medical images usually computes large number of image features, which creates a challenge of how to identify a small and optimal feature vector to build robust machine learning models, the objective of this study is to investigate feasibility of applying a random projection algorithm (RPA) to build an optimal feature vector from the initially CAD-generated large feature pool and improve performance of machine learning model.

METHODS

We assemble a retrospective dataset involving 1,487 cases of mammograms in which 644 cases have confirmed malignant mass lesions and 843 have benign lesions. A CAD scheme is first applied to segment mass regions and initially compute 181 features. Then, support vector machine (SVM) models embedded with several feature dimensionality reduction methods are built to predict likelihood of lesions being malignant. All SVM models are trained and tested using a leave-one-case-out cross-validation method. SVM generates a likelihood score of each segmented mass region depicting on one-view mammogram. By fusion of two scores of the same mass depicting on two-view mammograms, a case-based likelihood score is also evaluated.

RESULTS

Comparing with the principle component analyses, nonnegative matrix factorization, and Chi-squared methods, SVM embedded with RPA yielded a significantly higher case-based lesion classification performance with the area under ROC curve of 0.84 ± 0.01 (p<0.02).

CONCLUSION

The study demonstrates that RPA is a promising method to generate optimal feature vectors and improve SVM performance.

SIGNIFICANCE

This study presents a new method to develop CAD schemes with significantly higher and robust performance.

Synthesis of Radiolabeled Technetium- and Rhenium-Luteinizing Hormone-Releasing Hormone (99mTc/Re-Acdien-LHRH) Conjugates for Targeted Detection of Breast Cancer Cells Overexpressing the LHRH Receptor

Currently, ^186/188Re and ^99mTc are widely used radionuclides for cancer detection and diagnosis. New advancements in modalities and targeting strategies of radiopharmaceuticals will provide an opportunity to enhance imagery and detection of smaller colonies of cancer cells while lowering false-positive diagnoses. To understand the chemistry of agents derived from fac-[^99mTc(CO)₃(H₂O)₃]⁺ species, the nonradioactive [Re(CO)₃(H₂O)₃]⁺ analogue was used. We have designed and synthesized Re-Acdien-LHRH, Re-Acdien-peg-LHRH, and a radiolabeled ^99mTc-Acdien-LHRH (rhenium- and technetium-luteinizing hormone-releasing hormone) conjugates using a tridentate linker to detect cancers overexpressing the LHRH receptor. Re-Acdien-LHRH and Re-Acdien-peg-LHRH were synthesized from non-PEGylated and PEGylated LHRH-Acdien, respectively. Cellular uptake of the compounds ^99mTc-Acdien-LHRH, Re-Acdien-LHRH, and Re-Acdien-peg-LHRH was found to be significantly enhanced compared to that of untargeted ^99mTc alone and unlabeled [Re(CO)₃(H₂O)₃]⁺. In addition, the conjugate compounds showed no difference in cellular toxicity compared to untargeted ^99mTc alone or unlabeled [Re(CO)₃(H₂O)₃]⁺. Further, a competition assay using LHRH indicated selective targeting of Re-Acdien-peg-LHRH toward the LHRH receptor (p < 0.05) compared to that of [Re(CO)₃(H₂O)₃]⁺ alone. Together, our data show the design paradigm and synthesis of targeting radionuclides using the LHRH peptide. Our data suggests that utilizing the LHRH peptide can lead to selective targeting and diagnosis of breast cancers expressing the LHRH receptor.

Harms and Benefits of Cancer Screening

In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.

Altered Fecal Microbiota Signatures in Patients With Anxiety and Depression in the Gastrointestinal Cancer Screening: A Case-Control Study

Background: Increasing attention has been devoted to cancer screening and microbiota in recent decades, but currently there is less focus on microbiota characterization among screeners and its relationship to anxiety and depression. Methods: We characterized the microbial communities of fecal samples collected through the FOBT card from anxiety and depression screeners and paired controls in Henan, China (1:2, N = 69). DNA was extracted using the MOBIO PowerSoil kit. The V4 region of the 16S rRNA gene was sequenced using MiniSeq and processed using QIIME1. LEfSe was used to identify differentially abundant microbes, the Wilcoxon rank-sum test was used to test alpha diversity differences, and permutational multivariate analysis of variance was used to test for differences in beta diversity. Results: Similar fecal microbiota signatures in composition were found among screeners. The intestinal microbial environments by phylum were all composed primarily of Firmicutes, Bacteroidetes, and Proteobacteria, and the corresponding top genera were Faecalibacterium, Roseburia, and Prevotella. Compared with controls, the ranking of the top five genera in the anxiety and depression group changed, and the dominant genus was Prevotella in the anxiety and depression group and Faecalibacterium in the control group. There was a lower relative abundance of Gemmiger (1.4 vs. 2.3%, P = 0.025), Ruminococcus (0.6 vs. 0.8%, P = 0.037), and Veillonella (0.6 vs. 1.3%, P = 0.020). This may be linked to the lower alpha diversity in participants with anxiety and depression (Observed OTUs: 122.35 vs. 143.24; Chao1: 127.35 vs. 149.98), although no significant differences were observed. Distinct clustering in microbial composition between the two groups was detected for the Jaccard distance (P = 0.011). Conclusions: Our study showed differing microbial characterization among participants with anxiety and depression in the endoscopic screening of upper gastrointestinal cancer. Gemmiger, Ruminococcus, and Veillonella were informative and have potential clinical implications, which need to be confirmed by large-scale, prospective cohort studies and biological mechanism research.

Skin Electrical Resistance as a Diagnostic and Therapeutic Biomarker of Breast Cancer Measuring Lymphatic Regions

Skin changes associated with alterations in the interstitial matrix and lymph system might provide significant and measurable effects due to the presence of breast cancer. This study aimed to determine if skin electrical resistance changes could serve as a diagnostic and therapeutic biomarker associated with physiological changes in patients with malignant versus benign breast cancer lesions. Forty-eight women (24 with malignant cancer, 23 with benign lesions) were enrolled in this study. Repeated skin resistance measurements were performed within the same session and 1 week after the first measurement in the breast lymphatic region and non-breast lymphathic regions. Intraclass correlation coefficients were calculated to determine the technique's intrasession and intersession reproducibility. Data were then normalized as a mean of comparing cross-sectional differences between malignant and benign lesions of the breast. Six months longitudinal data from six patients that received therapy were analyzed to detect the effect of therapy. Standard descriptive statistics were used to compare ratiometric differences between groups. Skin resistance data were used to train a machine learning random forest classification algorithm to diagnose breast cancer lesions. Significant differences between malignant and benign breast lesions were obtained (p<0.01), also pre- and post-treatment (p<0.05). The diagnostic algorithm demonstrated the capability to classify breast cancer with an area under the curve of 0.68, sensitivity of 66.3%, specificity of 78.5%, positive predictive value 70.7% and negative predictive value 75.1%. Measurement of skin resistance in patients with breast cancer may serve as a convenient screening tool for breast cancer and evaluation of therapy. Further work is warranted to improve our approach and further investigate the biophysical mechanisms leading to the observed changes.

Overview in Breast Cancer Screening in Lebanon

Breast cancer (BC) is the most common cancer in women and men combined, and it is the second cause of cancer deaths in women after lung cancer. In Lebanon, the same epidemiological profile applies where BC is the leading cancer among Lebanese females, representing 38.2% of all cancer cases. As per the Center for Disease Control, there was a decline in BC mortality rate from 2003 to 2012 reflecting the adoption of national mammographic screening as the gold standard for BC detection by Western countries. The aim of this review study is to summarize current recommendations for BC screening and the available modalities for detecting BC in different countries, particularly in Lebanon. It also aims at exploring the impact of screening campaigns on BC early stage diagnosis in Lebanon. Despite the considerable debates whether screening mammograms provides more harm than benefits, screening awareness should be stressed since its benefits far outweigh its risks. In fact, the majority of BC mortality cases in Western countries are non-preventable by the use of screening mammograms alone. As such, Lebanon adopted a public focus on education and awareness campaigns encouraging early BC screening. Several studies showed the impact of early detection that is reflected by an increase in early stage disease and a decrease in more aggressive stages. Further studies should shed the light on the effect of awareness campaigns on early breast cancer diagnosis and clinical down staging at a national scope; therefore, having readily available data on pre- and post-adoption of screening campaigns is crucial for analyzing trends in mortality of breast cancer origin and reduction in advanced stages diseases. There is still room for future studies evaluating post-campaigns knowledge, attitudes, and practices of women having participated, emphasizing on the barriers refraining Lebanese women to contribute in BC screening campaigns.

Consumer health informatics approach for personalized cancer screening decisions using utility functions

A consumer health informatics approach is used to investigate the development of a patient-centered decision support system (DSS) with individualized utility functions. It supports medical decisions that have uncertain benefits and potential harms. Its use for accepting or declining cancer screening is illustrated. The system's underlying optimization model incorporates two user-specific utility functions-one that quantifies life-saving benefits and one that quantifies harms, such as unnecessary follow-up tests, surgeries, or treatments. The system requires sound decision making. Therefore, the decision making process was studied using a decision aid in the form of a color-coded matrix with the potential outcomes randomly placed in proportion to their likelihoods. Data were collected from 48 study participants, based on a central composite experimental design. The results show that the DSS can be effective, but health consumers may not be rational decision makers.

Spiral breast computed tomography (CT): signal-to-noise and dose optimization using 3D-printed phantoms

Objectives

To investigate the dependence of signal-to-noise ratio (SNR) and calculated average dose per volume of spiral breast-CT (B-CT) on breast size and breast density and to provide a guideline for choosing the optimal tube current for each B-CT examination.

Materials and methods

Three representative B-CT datasets (small, medium, large breast size) were chosen to create 3D-printed breast phantoms. The phantoms were filled with four different agarose-oil-emulsions mimicking differences in breast densities. Phantoms were scanned in a B-CT system with systematic variation of the tube current (6, 12.5, 25, 32, 40, 50, 64, 80, 100, 125 mA). Evaluation of SNR and the average dose per volume using Monte Carlo simulations were performed for high (HR) and standard (STD) spatial resolution.

Results

SNR and average dose per volume increased with increasing tube current. Artifacts had negligible influence on image evaluation. SNR values ≥ 35 (HR) and ≥ 100 (STD) offer sufficient image quality for clinical evaluation with SNR being more dependent on breast density than on breast size. For an average absorbed dose limit of 6.5 mGy for the medium and large phantoms and 7 mGy for the small phantom, optimal tube currents were either 25 or 32 mA.

Conclusions

B-CT offers the possibility to vary the X-ray tube current, allowing image quality optimization based on individual patient’s characteristics such as breast size and density. This study describes the optimal B-CT acquisition parameters, which provide diagnostic image quality for various breast sizes and densities, while keeping the average dose at a level similar to digital mammography.

Key Points

• Image quality optimization based on breast size and density varying the tube current using spiral B-CT.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-020-07549-3.

The accuracy of a novel sonographic scanning and reporting protocol to survey for soft tissue sarcoma local recurrence

OBJECTIVE

This study aims to determine the accuracy of a novel ultrasonography (US) scanning and reporting protocol to detect recurrences. The secondary aim is to compare US and MRI accuracy and agreement.

MATERIALS AND METHODS

In this IRB-approved prospective study, consecutive patients presenting for MRI surveillance after resection were enrolled and underwent same-day US. Blinded to clinical information and the MRI, the US scanner characterized lesions using a proposed novel lexicon. Outcome was defined either by histology or a subsequent MRI scan confirming the presence or absence of recurrence. Fisher's exact test and Kappa test were performed to assess of the significance and agreement between US, MRI, and outcome.

RESULTS

A total of 68 US scans were performed on 55 patients. The overall accuracy to diagnose recurrence was the same for US and MRI (92.6%) while US was less sensitive (75.0% vs. 91.7%) but more specific (97.6% vs. 92.9%) than MRI. The two lesions missed by US but not MRI were an entirely intraosseous metastasis and a subcentimeter skin nodule. There was strong agreement between US and MRI with outcome (k = 0.787 and 0.801, respectively).

CONCLUSIONS

These pilot data suggest the accuracy of this novel US local recurrence surveillance method is comparable to MRI. A multi-institutional prospective trial would increase power and determine reproducibility.

Is Ultrasound an Accurate Alternative for Mammography in Breast Cancer Screening in an Asian Population? A Meta-Analysis

In Asian countries, ultrasound has been proposed as a possible alternative for mammography in breast cancer screening because of its superiority in dense breasts, accessibility and low costs. This research aimed to meta-analyze the evidence for the diagnostic performance of ultrasound compared to mammography for breast cancer screening in Asian women. PubMed, Web of Science, and China National Knowledge Infrastructure databases were searched for studies that concurrently compared mammography and ultrasound in 2000-2019. Data extraction and risk of bias were performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) statement. The primary outcome was the sensitivity and specificity. Bivariate random models were used to generate pooled estimates of diagnostic parameters and 95% confidence intervals (95% CI). In total, 4424 studies were identified of which six studies met the inclusion criteria with a sample size of 124,425 women. The pooled mean prevalence of the included studies was 3.7‱ (range: 1.2-5.7‱). The pooled sensitivity of mammography was significantly higher than that of ultrasound (0.81 [95% CI 0.71-0.88] versus 0.65 [95% CI 0.58-0.72], p = 0.03), but no significant differences were found in specificity (0.98 [95% CI: 0.94-1.00] versus 0.99 [95% CI: 0.97-1.00], p = 0.65). In conclusion, based on the currently available data on sensitivity alone, there is no indication that ultrasound can replace mammography in breast cancer screening in Asian women.

Screening for Breast Cancer

Among women, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related death in the world. The purpose of this article is to review the evidence regarding breast cancer screening for average-risk women. The review primarily focuses on mammographic screening but also reviews clinical breast examinations, emerging screening technologies, and opportunities to build consensus. Wherever possible, the review relies on published systematic reviews, meta-analyses, and guidelines from three major societies (US Preventive Services Task Force, American College of Radiology, and the American Cancer Society) to reflect a range of evidence-based perspectives regarding mammographic screening.

Contrast-Enhanced Digital Mammography: Technique, Clinical Applications, and Pitfalls

OBJECTIVE. Contrast-enhanced digital mammography (CEDM) combines the high spatial resolution of mammography with the improved enhancement provided by contrast medium. In this article, CEDM technique-the current and potential clinical applications and current challenges-will be reviewed. CONCLUSION. CEDM is a promising technique in the supplemental evaluation of patients with mammographically inconclusive findings and potentially in the screening of women with mammographically dense breasts. CEDM is emerging as a cost-effective alternative to dynamic contrast-enhanced MRI to stage newly diagnosed breast cancer and evaluate response to neoadjuvant chemotherapy.

Cancer Screening in Older Adults: Individualized Decision-Making and Communication Strategies

Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered more effective, easy to understand, and acceptable by older adults and clinicians.

Comparison of interval breast cancers with 2D digital mammography versus 3D digital breast tomosynthesis in a large community-based practice

Incidence of interval cancers is an important outcome in assessing efficacy of screening. Our primary objective was to compare the incidence of interval cancers detected with two-dimensional digital mammography (DM) versus digital breast tomosynthesis (DBT) in a large community health system. Our secondary objectives were to compare the patient and tumor characteristics of interval cancers, cancer detection rate, and recall rate. Interval cancers before and after implementation of DBT (2012-2014 DM group; 2016-2018 DBT group) were reviewed. Patient factors (age, race, breast density, personal history of breast cancer, family history of breast cancer, known BRCA-1 or BRCA-2 genetic mutation, baseline mammogram, and presentation) and tumor characteristics (in situ versus invasive, grade, size, hormone receptor status, and nodal status) were compared with the chi-squared test or the MidP exact test. Rates (detection and recall) were compared using a z-score. The rates of interval cancers with DM (0.30 per 1000 [35/117 099]) and DBT (0.33 per 1000 [40/119 746]) were similar (P = .3). Proportion of node-positive interval cancers was lower in the DBT group (22.9% [8/35] vs 48% [15/31], p.01). Otherwise, the patient and tumor characteristics were similar. The cancer detection rate increased (5.9 per 1000 [709/119 746] vs 3.5 per 1000 [411/117 099], P = .0001), and the recall rate decreased with DBT (8.6% [10 347/119 746] versus 10.7% [12 508/117 099], (P < .0001). Although the cancer detection rate was higher with DBT, the rate of interval breast cancers was similar in both groups. Node-positive invasive interval cancers were decreased with DBT.

An Overview of Promising Biomarkers in Cancer Screening and Detection

Applications of biomarkers have been proved in oncology screening, diagnosis, predicting response to treatment as well as monitoring the progress of the disease. Considering the crucial role played by them during different disease stages, it is extremely important to evaluate, validate, and assess them to incorporate them into routine clinical care. In this review, the role of few most promising and successfully used biomarkers in cancer detection, i.e. PD-L1, E-Cadherin, TP53, Exosomes, cfDNA, EGFR, mTOR with regard to their structure, mode of action, and reports signifying their pathological significance, are addressed. Also, an overview of some successfully used biomarkers for cancer medicine has been presented. The study also summarizes biomarker-driven personalized cancer therapy i.e., approved targets and indications, as per the US FDA. The review also highlights the increasingly prominent role of biomarkers in drug development at all stages, with particular reference to clinical trials. The increasing utility of biomarkers in clinical trials is clearly evident from the trend shown, wherein ~55 percent of all oncology clinical trials in 2019 were seen to involve biomarkers, as opposed to ~ 15 percent in 2001, which clearly proves the essence and applicability of biomarkers for synergizing clinical information with tumor progression. Still, there are significant challenges in the implementation of these possibilities with strong evidence in cost-- effective manner.

Heparanase Promotes Syndecan-1 Expression to Mediate Fibrillar Collagen and Mammographic Density in Human Breast Tissue Cultured ex vivo

Mammographic density (MD) is a strong and independent factor for breast cancer (BC) risk and is increasingly associated with BC progression. We have previously shown in mice that high MD, which is characterized by the preponderance of a fibrous stroma, facilitates BC xenograft growth and metastasis. This stroma is rich in extracellular matrix (ECM) factors, including heparan sulfate proteoglycans (HSPGs), such as the BC-associated syndecan-1 (SDC1). These proteoglycans tether growth factors, which are released by heparanase (HPSE). MD is positively associated with estrogen exposure and, in cell models, estrogen has been implicated in the upregulation of HPSE, the activity of which promotes SDC expression. Herein we describe a novel measurement approach (single-sided NMR) using a patient-derived explant (PDE) model of normal human (female) mammary tissue cultured ex vivo to investigate the role(s) of HPSE and SDC1 on MD. Relative HSPG gene and protein analyses determined in patient-paired high vs. low MD tissues identified SDC1 and SDC4 as potential mediators of MD. Using the PDE model we demonstrate that HPSE promotes SDC1 rather than SDC4 expression and cleavage, leading to increased MD. In this model system, synstatin (SSTN), an SDC1 inhibitory peptide designed to decouple SDC1-ITGαvβ3 parallel collagen alignment, reduced the abundance of fibrillar collagen as assessed by picrosirius red viewed under polarized light, and reduced MD. Our results reveal a potential role for HPSE in maintaining MD via its direct regulation of SDC1, which in turn physically tethers collagen into aligned fibers characteristic of MD. We propose that inhibitors of HPSE and/or SDC1 may afford an opportunity to reduce MD in high BC risk individuals and reduce MD-associated BC progression in conjunction with established BC therapies.

The cost-effectiveness of digital breast tomosynthesis in a population breast cancer screening program

OBJECTIVES

To evaluate at which sensitivity digital breast tomosynthesis (DBT) would become cost-effective compared to digital mammography (DM) in a population breast cancer screening program, given a constant estimate of specificity.

METHODS

In a microsimulation model, the cost-effectiveness of biennial screening for women aged 50-75 was simulated for three scenarios: DBT for women with dense breasts and DM for women with fatty breasts (scenario 1), DBT for the whole population (scenario 2) or maintaining DM screening (reference). For DM, sensitivity was varied depending on breast density from 65 to 87%, and for DBT from 65 to 100%. The specificity was set at 96.5% for both DM and DBT. Direct medical costs were considered, including screening, biopsy and treatment costs. Scenarios were considered to be cost-effective if the incremental cost-effectiveness ratio (ICER) was below €20,000 per life year gain (LYG).

RESULTS

For both scenarios, the ICER was more favourable at increasing DBT sensitivity. Compared with DM screening, 0.8-10.2% more LYGs were found when DBT sensitivity was at least 75% for scenario 1, and 4.7-18.7% when DBT sensitivity was at least 80% for scenario 2. At €96 per DBT, scenario 1 was cost-effective at a DBT sensitivity of at least 90%, and at least 95% for scenario 2. At €80 per DBT, these values decreased to 80% and 90%, respectively.

CONCLUSION

DBT is more likely to be a cost-effective alternative to mammography in women with dense breasts. Whether DBT could be cost-effective in a general population highly depends on DBT costs.

KEY POINTS

• DBT could be a cost-effective screening modality for women with dense breasts when its sensitivity is at least 90% at a maximum cost per screen of €96. • DBT has the potential to be cost-effective for screening all women when sensitivity is at least 90% at a maximum cost per screen of €80. • Whether DBT could be used as an alternative to mammography for screening all women is highly dependent on the cost of DBT per screen.

New mammography screening performance metrics based on the entire screening episode

BACKGROUND

Established mammography screening performance metrics use the initial screening mammography assessment because they were developed for radiologist performance auditing, yet these metrics are frequently used to inform health policy and screening decision making. The authors have developed new performance metrics based on the final assessment that consider the entire screening episode, including diagnostic workup.

METHODS

The authors used data from 2,512,577 screening episodes during 2005-2017 at 146 facilities in the United States participating in the Breast Cancer Surveillance Consortium. Screening performance metrics based on the final assessment of the screening episode were compared with conventional metrics defined with the initial assessment. Results were also stratified by breast density and breast cancer risk.

RESULTS

The cancer detection rates were similar for the final assessment (4.1 per 1000; 95% confidence interval [CI], 3.8-4.3 per 1000) and the initial assessment (4.1 per 1000; 95% CI, 3.9-4.3 per 1000). The interval cancer rate was 12% higher when it was based on the final assessment (0.77 per 1000; 95% CI, 0.71-0.83 per 1000) versus the initial assessment (0.69 per 1000; 95% CI, 0.64-0.74 per 1000), and this resulted in a modest difference in sensitivity (84.1% [95% CI, 83.0%-85.1%] vs 85.7% [95% CI, 84.8%-86.6%], respectively). Absolute differences in the interval cancer rate between final and initial assessments increased with breast density and breast cancer risk (eg, a difference of 0.29 per 1000 for women with extremely dense breasts and a 5-year risk >2.49%).

CONCLUSIONS

Established screening performance metrics underestimate the interval cancer rate of a mammography screening episode, particularly for women with dense breasts or an elevated breast cancer risk. Women, clinicians, policymakers, and researchers should use final-assessment performance metrics to support informed screening decisions.

False-positive mammography and mammography screening intentions among black women: the influence of emotions and coping strategies

Introduction: Abnormal mammograms confirmed as benign are known as false-positive mammography (FPM) results. Research indicates that a history of FPM results may be linked to diagnostic delays in Black women, yet much of the research on FPM has focused on White women.Objectives: The purpose of this study was to examine: 1) The influence of FPM on breast cancer (BrCa) screening beliefs and intentions among Black women and 2) Whether emotional states, personality traits or coping behaviors altered the previously described relationships.Design: BrCa-free, Black women, aged 40 and older who completed screening mammograms in 2016 were recruited for a case-control study from 2016 to 2017. Women with FPM results were cases, and women with normal results served as matched controls. Print surveys assessing demographics, personality traits, emotions, BrCa screening history, BrCa beliefs, and africentric coping behaviors were mailed to participants. The final sample consisted of 118 respondents (55 cases, 63 controls). Ordinary least squares (OLS) models were constructed. Personality traits and emotions were tested as mediators and coping behaviors as moderators of the relationship between FPM results and BrCa beliefs.Results: FPM status was associated with a higher perception of barriers to mammography, and an elevated perception of barriers was associated with lower intentions to complete mammography. Collective coping behaviors functioned as a moderator and were associated with a decreased perception of mammography barriers in women with FPM results.Conclusions: FPM status had a detrimental impact on mammography intention indirectly through the perception of mammography barriers, but the use of africentric coping behaviors moderated the relationship between FPM status and perceived barriers to mammography. Culturally specific research focused on Black women is needed to explore influences on BrCa screening beliefs and mammography completion in this population.

Value of Hand-held Ultrasound in the Differential Diagnosis and Accurate Breast Imaging Reporting and Data System Subclassification of Complex Cystic and Solid Breast Lesions

To explore the value of hand-held ultrasound (HHUS) for diagnosing complex cystic and solid breast lesions, 472 pathologically proven lesions were analyzed. The lesions were divided into four types based on ultrasound features. Positive predictive values (PPVs) for lesion types and risk factor performances were assessed. Furthermore, HHUS and mammography (MAM) performances were compared: 27 lesions missed in MAM were detected in HHUS. Ultrasound feature analysis revealed higher PPVs for type III and IV lesions than for type I and II lesions. In patients older than 51 y, a type III or IV lesion with a diameter greater than 18 mm, an irregular shape, a non-parallel orientation, an uncircumscribed margin, calcification, vascularity and abnormal axillary lymph nodes were suggestive of malignancy; the area under the curve reached 0.869. Thus, ultrasound is useful in diagnosing complex cystic and solid breast lesions, which should be categorized as Breast Imaging Reporting and Data System (BI-RADS) 4B or 4C.

Use of an Online Breast Cancer Risk Assessment and Patient Decision Aid in Primary Care Practices

Background: U.S. Preventive Services Task Force (USPSTF) recommendations for mammography screening, genetic counseling and testing for pathogenic BRCA1/2 mutations, and use of risk-reducing medications require assessment of breast cancer risk for clinical decision-making, but efficient methods for risk assessment in clinical practice are lacking. Materials and Methods: A cross-sectional study evaluating a web-based breast cancer risk assessment and decision aid (MammoScreen) was conducted in an academic general internal medicine clinic. All eligible women, 40-74 years of age without previous diagnosis of breast or ovarian cancer and who were enrolled in the Epic MyChart patient portal were invited. MammoScreen uptake and completion rates and consistency between breast cancer risk determined by MammoScreen and existing risk information in the Epic record were measured. Patient and physician experiences were summarized from interviews. Results: Of 448 invited participants, 339 (75.7%) read their MyChart invitation and 125 (36.9%) who read invitations enrolled in the study; 118 (94.4% of enrolled) completed MammoScreen. Twenty-one women were categorized as above-average risk from either MammoScreen data or the chart review and 7 (33.3%) were identified by both sources. Physicians and patients believed MammoScreen was easy to use and was helpful in identifying risks and facilitating shared decision-making. Conclusions: Breast cancer risk assessment and mammography screening decision support were efficiently implemented through a web-based tool for patients sent through an electronic patient portal. Integration of patient decision aids with risk algorithms in clinical practice may help support the implementation of USPSTF recommendations that include risk assessment and shared decision-making.

Breast Cancer Detection-A Synopsis of Conventional Modalities and the Potential Role of Microwave Imaging

Global statistics have demonstrated that breast cancer is the most frequently diagnosed invasive cancer and the leading cause of cancer death among female patients. Survival following a diagnosis of breast cancer is grossly determined by the stage of the disease at the time of initial diagnosis, highlighting the importance of early detection. Improving early diagnosis will require a multi-faceted approach to optimizing the use of currently available imaging modalities and investigating new methods of detection. The application of microwave technologies in medical diagnostics is an emerging field of research, with breast cancer detection seeing the most significant progress in the last twenty years. In this review, the application of current conventional imaging modalities is discussed, and recurrent shortcomings highlighted. Microwave imaging is rapid and inexpensive. If the preliminary results of its diagnostic capacity are substantiated, microwave technology may offer a non-ionizing, non-invasive, and painless adjunct or stand-alone modality that could possibly be implemented in routine diagnostic breast care.

Importance of quality in breast cancer screening practice - a natural experiment in Alberta, Canada

OBJECTIVES

Regular breast cancer screening is a widely used cancer prevention strategy. Important quality indicators of screening include cancer detection rate, false positive rate, benign biopsy rate and post-screen invasive cancer rate. We compared quality indicators of community radiology clinics to those of 'Screen Test', which feature centralised batch reading and quality control processes. Both types of providers operated under a single provincial Breast Cancer Screening Programme.

SETTING

Community radiology clinics are operated by independent fee-for-service radiologists serving large and small communities throughout the Canadian province of Alberta. Launched by the provincial cancer agency, the Screen Test operates two physical clinics serving metropolises and mobile units serving remote regions. Eligible women may self-refer to any provider for screening mammography.

PARTICIPANTS

Women aged 50 to 69 years who had at least one screening mammogram between July 2006 and June 2010 in Alberta were included. Women with missing health region information or prior breast cancer diagnosis were excluded.

RESULTS

A total of 389 788 screening mammograms were analysed, of which 12.7% were performed by Screen Test. Compared with Screen Test during 2006 to 2008, community radiology clinics had a lower cancer detection rate (3.6 vs 4.6 per 1000 screens, risk ratio (RR): 0.81, 95% CI: 0.67 to 0.98) and a much higher false positive rate (9.4% vs 3.4%, RR: 2.72, 95% CI: 2.55 to 2.90). Most other performance indicators were also better in Screen Test overall and across all health regions. These performance indicators were similar during 2008 to 2010, showing no improvement with time.

CONCLUSIONS

Screen Test has a quality assurance process in place and performed significantly better. This provides empirical evidence of the effectiveness of a quality assurance process and may explain some of the large differences in breast cancer screening indicators between provinces and countries with formal programmes and those without.

Age-related disparities in older women with breast cancer

Improvements in breast cancer (BC) mortality rates have not been seen in the older adult community, and the fact that older adults are more likely to die from their cancer than younger women establishes a major health disparity. Studies have identified that despite typically presenting with more favorable histology, older women present with more advanced disease, which may be related in part to delayed diagnosis. This is supported by examination of screening practices in older adults. Older women have a worse prognosis than younger women in both early stage disease, and more advanced and metastatic disease. Focus on the treatment of older adults has often concentrated on avoiding overtreatment, but in fact undertreatment may be one reason for the age-related differences in outcomes, and treatments need to be individualized for every older adult, and take into account patient preferences and functional status and not chronologic age alone. Given the aging population in the US, identifying methods to improve early diagnosis in this population and identify additional factors will be important to reducing this age-related disparity.

Early detection of cancer using circulating tumor DNA: biological, physiological and analytical considerations

Early diagnosis of cancer improves the efficacy of curative therapies. However, due to the difficulties involved in distinguishing between small early-stage tumors and normal biological variation, early detection of cancer is an extremely challenging task and there are currently no clinically validated biomarkers for a pan-cancer screening test. It is thus of particular significance that increasing evidence indicates the potential of circulating tumor DNA (ctDNA) molecules, which are fragmented segments of DNA shed from tumor cells into adjacent body fluids and the circulatory system, to serve as molecular markers for early cancer detection and thereby allow early intervention and improvement of therapeutic and survival outcomes. This is possible because ctDNA molecules bear cancer-specific fragmentation patterns, nucleosome depletion motifs, and genetic and epigenetic alterations, as distinct from plasma DNA originating from non-cancerous tissues/cells. Compared to traditional biomarkers, ctDNA analysis therefore presents the distinctive advantage of detecting tumor-specific alterations. However, based on a thorough survey of the literature, theoretical and empirical evidence suggests that current ctDNA analysis strategies, which are mainly based on DNA mutation detection, do not demonstrate the necessary diagnostic sensitivity and specificity that is required for broad clinical implementation in a screening context. Therefore, in this review we explain the biological, physiological, and analytical challenges toward the development of clinically meaningful ctDNA tests. In addition, we explore some approaches that can be implemented in order to increase the sensitivity and specificity of ctDNA assays.

A Circulating miRNA Signature for Stratification of Breast Lesions among Women with Abnormal Screening Mammograms

Although mammography is the gold standard for breast cancer screening, the high rates of false-positive mammograms remain a concern. Thus, there is an unmet clinical need for a non-invasive and reliable test to differentiate between malignant and benign breast lesions in order to avoid subjecting patients with abnormal mammograms to unnecessary follow-up diagnostic procedures. Serum samples from 116 malignant breast lesions and 64 benign breast lesions were comprehensively profiled for 2,083 microRNAs (miRNAs) using next-generation sequencing. Of the 180 samples profiled, three outliers were removed based on the principal component analysis (PCA), and the remaining samples were divided into training (n = 125) and test (n = 52) sets at a 70:30 ratio for further analysis. In the training set, significantly differentially expressed miRNAs (adjusted p < 0.01) were identified after correcting for multiple testing using a false discovery rate. Subsequently, a predictive classification model using an eight-miRNA signature and a Bayesian logistic regression algorithm was developed. Based on the receiver operating characteristic (ROC) curve analysis in the test set, the model could achieve an area under the curve (AUC) of 0.9542. Together, this study demonstrates the potential use of circulating miRNAs as an adjunct test to stratify breast lesions in patients with abnormal screening mammograms.

Factors Impacting False Positive Recall in Screening Mammography

RATIONALE AND OBJECTIVES

Our objective was to identify factors impacting false positive recalls in screening mammography.

MATERIALS AND METHODS

We retrospectively reviewed our screening mammography database from August 31, 2015 to September 30, 2016, including full field digital mammograms (FFDM) and digital breast tomosynthesis (DBT) mammograms. False positive (FP) exams were defined as Breast Imaging-Reporting and Data System (BI-RADS) 1 or 2 assessments at diagnostic imaging with 1 year cancer-free follow-up, Breast Imaging-Reporting and Data System 3 assessment at diagnostic imaging with 2 years cancer free follow-up, or biopsy with benign pathology. True positives were defined as malignant pathology on biopsy or surgical excision. We evaluated the association of FP recalls with multiple patient-level factors and imaging features.

RESULTS

A total of 22,055 screening mammograms were performed, and 1887 patients were recalled (recall rate 8.6%). Recall rate was lower for DBT than full field digital mammograms (8.0% vs 10.6%, p < 0.001). FP results were lower if prior mammograms were available (90.8% vs 95.8%, p = 0.02), and if there was a previous benign breast biopsy (87.6% vs 92.9%, p = 0.01). Mean age for the FP group was lower than the true positive group (56.1 vs 62.9 years, p < 0.001). There were no significant differences in FP recalls based on history of high-risk lesions, family history of breast or ovarian cancer, hormone use, breast density, race, or body mass index.

CONCLUSION

FP recalls were significantly less likely with DBT, in older women, in patients with prior mammograms available for comparison, and in patients with histories of benign breast biopsy. This study supports the importance of using DBT in the screening setting and obtaining prior mammograms for comparison.