Comparing sensitivity and specificity of screening mammography in the United States and Denmark

Familiarity, confidence and preference of artificial intelligence feedback and prompts by Australian breast cancer screening readers

Objectives This study explored the familiarity, perceptions and confidence of Australian radiology clinicians involved in reading screening mammograms, regarding artificial intelligence (AI) applications in breast cancer detection. Methods Sixty-five radiologists, breast physicians and radiology trainees participated in an online survey that consisted of 23 multiple choice questions asking about their experience and familiarity with AI products. Furthermore, the survey asked about their confidence in using AI outputs and their preference for AI modes applied in a breast screening context. Participants' responses to questions were compared using Pearson's χ 2 test. Bonferroni-adjusted significance tests were used for pairwise comparisons. Results Fifty-five percent of respondents had experience with AI in their workplaces, with automatic density measurement powered by machine learning being the most familiar AI product (69.4%). The top AI outputs with the highest ranks of perceived confidence were 'Displaying suspicious areas on mammograms with the percentage of cancer possibility' (67.8%) and 'Automatic mammogram classification (normal, benign, cancer, uncertain)' (64.6%). Radiology and breast physicians preferred using AI as second-reader mode (75.4% saying 'somewhat happy' to 'extremely happy') over triage (47.7%), pre-screening and first-reader modes (both with 26.2%) (P  < 0.001). Conclusion The majority of screen readers expressed increased confidence in utilising AI for highlighting suspicious areas on mammograms and for automatically classifying mammograms. They considered AI as an optimal second-reader mode being the most ideal use in a screening program. The findings provide valuable insights into the familiarities and expectations of radiologists and breast clinicians for the AI products that can enhance the effectiveness of the breast cancer screening programs, benefitting both healthcare professionals and patients alike.

Fertility Preservation in BRCA1/2 Germline Mutation Carriers: An Overview

BRCA1 and BRCA2 mutations are responsible for a higher incidence of breast and ovarian cancer (from 55% up to 70% vs. 12% in the general population). If their functions have been widely investigated in the onset of these malignancies, still little is known about their role in fertility impairment. Cancer patients treated with antineoplastic drugs can be susceptible to their gonadotoxicity and, in women, some of them can induce apoptotic program in premature ovarian follicles, progressive depletion of ovarian reserve and, consequently, cancer treatment-related infertility (CTRI). BRCA variants seem to be associated with early infertility, thus accelerating treatment impairment of ovaries and making women face the concrete possibility of an early pregnancy. In this regard, fertility preservation (FP) procedures should be discussed in oncofertility counseling-from the first line of prevention with risk-reducing salpingo-oophorectomy (RRSO) to the new experimental ovarian stem cells (OSCs) model as a new way to obtain in vitro-differentiated oocytes, several techniques may represent a valid option to BRCA-mutated patients. In this review, we revisit knowledge about BRCA involvement in lower fertility, pregnancy feasibility, and the fertility preservation (FP) options available.

Advantages of contrast-enhanced ultrasound in the localization and diagnostics of sentinel lymph nodes in breast cancer

Sentinel lymph nodes (SLNs) are the first station of lymph nodes that extend from the breast tumor to the axillary lymphatic drainage. The pathological status of these LNs can predict that of the entire axillary lymph node. Therefore, the accurate identification of SLNs is necessary for sentinel lymph node biopsy (SLNB) to replace axillary lymph node dissection (ALND). The quality of life and prognosis of breast cancer patients are related to proper surgical treatment after the precise identification of SLNs. Some of the SLN tracers that have been identified include radioisotope, nano-carbon, indocyanine green (ICG), and methylene blue (MB). However, these tracers have certain limitations, such as pigmentation, radiation dangers, and the requirement for costly detection equipment. Ultrasound contrast agents (UCAs) have good specificity and sensitivity, and thus can compensate for some shortcomings of the mentioned tracers. This technique is also being applied to SLNB in patients with breast cancer, and can even provide an initial judgment on SLN status. Contrast-enhanced ultrasound (CEUS) has the advantages of high distinguishability, simple operation, no radiation harm, low cost, and accurate localization; therefore, it is expected to replace the traditional biopsy methods. In addition, it can significantly enhance the accuracy of SLN localization and shorten the operation time.

Malmö Breast ImaginG database: objectives and development

Purpose

We describe the design and implementation of the Malmö Breast ImaginG (M-BIG) database, which will support research projects investigating various aspects of current and future breast cancer screening programs. Specifically, M-BIG will provide clinical data to:1.investigate the effect of breast cancer screening on breast cancer prognosis and mortality;2.develop and validate the use of artificial intelligence and machine learning in breast image interpretation; and3.develop and validate image-based radiological breast cancer risk profiles.

Approach

The M-BIG database is intended to include a wide range of digital mammography (DM) and digital breast tomosynthesis (DBT) examinations performed on women at the Mammography Clinic in Malmö, Sweden, from the introduction of DM in 2004 through 2020. Subjects may be included multiple times and for diverse reasons. The image data are linked to extensive clinical, diagnostic, and demographic data from several registries.

Results

To date, the database contains a total of 451,054 examinations from 104,791 women. During the inclusion period, 95,258 unique women were screened. A total of 19,968 examinations were performed using DBT, whereas the rest used DM.

Conclusions

We describe the design and implementation of the M-BIG database as a representative and accessible medical image database linked to various types of medical data. Work is ongoing to add features and curate the existing data.

Test sensitivity in a prospective cancer screening program: A critique of a common proxy measure

The true sensitivity of a cancer screening test, defined as the frequency with which the test returns a positive result if the cancer is present, is a key indicator of diagnostic performance. Given the challenges of directly assessing test sensitivity in a prospective screening program, proxy measures for true sensitivity are frequently reported. We call one such proxy empirical sensitivity, as it is given by the observed ratio of screen-detected cancers to the sum of screen-detected and interval cancers. In the setting of the canonical three-state Markov model for progression from preclinical onset to clinical diagnosis, we formulate a mathematical relationship for how empirical sensitivity varies with the screening interval and the mean preclinical sojourn time and identify conditions under which empirical sensitivity exceeds or falls short of true sensitivity. In particular, when the inter-screening interval is short relative to the mean sojourn time, empirical sensitivity tends to exceed true sensitivity, unless true sensitivity is high. The Breast Cancer Surveillance Consortium (BCSC) has reported an estimate of 0.87 for the empirical sensitivity of digital mammography. We show that this corresponds to a true sensitivity of 0.82 under a mean sojourn time of 3.6 years estimated based on breast cancer screening trials. However, the BCSC estimate of empirical sensitivity corresponds to even lower true sensitivity under more contemporary, longer estimates of mean sojourn time. Consistently applied nomenclature that distinguishes empirical sensitivity from true sensitivity is needed to ensure that published estimates of sensitivity from prospective screening studies are properly interpreted.

Improving the Quantitative Analysis of Breast Microcalcifications: A Multiscale Approach

Accurate characterization of microcalcifications (MCs) in 2D digital mammography is a necessary step toward reducing the diagnostic uncertainty associated with the callback of indeterminate MCs. Quantitative analysis of MCs can better identify MCs with a higher likelihood of ductal carcinoma in situ or invasive cancer. However, automated identification and segmentation of MCs remain challenging with high false positive rates. We present a two-stage multiscale approach to MC segmentation in 2D full-field digital mammograms (FFDMs) and diagnostic magnification views. Candidate objects are first delineated using blob detection and Hessian analysis. A regression convolutional network, trained to output a function with a higher response near MCs, chooses the objects which constitute actual MCs. The method was trained and validated on 435 screening and diagnostic FFDMs from two separate datasets. We then used our approach to segment MCs on magnification views of 248 cases with amorphous MCs. We modeled the extracted features using gradient tree boosting to classify each case as benign or malignant. Compared to state-of-the-art comparison methods, our approach achieved superior mean intersection over the union (0.670 ± 0.121 per image versus 0.524 ± 0.034 per image), intersection over the union per MC object (0.607 ± 0.250 versus 0.363 ± 0.278) and true positive rate of 0.744 versus 0.581 at 0.4 false positive detections per square centimeter. Features generated using our approach outperformed the comparison method (0.763 versus 0.710 AUC) in distinguishing amorphous calcifications as benign or malignant.

Cumulative risks of false positive recall and screen-detected breast cancer after multiple screening examinations

Women tend to make a decision about participation in breast cancer screening and adhere to this for future invitations. Therefore, our study aimed to provide high-quality information on cumulative risks of false-positive (FP) recall and screen-detected breast cancer over multiple screening examinations. Individual Dutch screening registry data (2005-2018) were gathered on subsequent screening examinations of 92 902 women age 49 to 51 years in 2005. Survival analyses were used to calculate cumulative risks of a FP and a true-positive (TP) result after seven examinations. Data from 66 472 women age 58 to 59 years were used to extrapolate to 11 examinations. Participation, detection and additional FP rates were calculated for women who previously received FP results compared to women with true negative (TN) results. After 7 examinations, the cumulative risk of a TP result was 3.7% and the cumulative risk of a FP result was 9.1%. After 11 examinations, this increased to 7.1% and 13.5%, respectively. Following a FP result, participation was lower (71%-81%) than following a TN result (>90%). In women with a FP result, more TP results (factor 1.59 [95% CI: 1.44-1.72]), more interval cancers (factor 1.66 [95% CI: 1.41-1.91]) and more FP results (factor 1.96 [95% CI: 1.87-2.05]) were found than in women with TN results. In conclusion, due to a low recall rate in the Netherlands, the cumulative risk of a FP recall is relatively low, while the cumulative risk of a TP result is comparable. Breast cancer diagnoses and FP results were more common in women with FP results than in women with TN results, while participation was lower.

The Impact of Prior Mammograms on the Diagnostic Performance of Radiologists in Early Breast Cancer Detection: A Focus on Breast Density, Lesion Features and Vendors Using Wholly Digital Screening Cases

BACKGROUND

This study aims to investigate the diagnostic efficacy of radiologists when reading screening mammograms in the absence of previous images, and with the presence of prior images from the same and different vendors.

METHODS

612 radiologists' readings across 9 test sets, consisting of 540 screening mammograms (361-normal and 179-cancer) with 245 cases having prior images obtained from same vendor as current images, 129 from a different vendor and 166 cases having no prior images, were retrospectively analysed. True positive (sensitivity), true negative (specificity) and area under ROC curve (AUC) values of radiologists were calculated for three groups of cases (without prior images (NP), with prior images from same vendor (SP), and with prior images from different vendor (DP)). Logistic regression was used to estimate the odds ratio (OR) of true positive, true negative and true cancer localization among case groups with different levels of breast density and lesion characteristics.

RESULTS

Radiologists obtained 12.8% and 10.3% higher sensitivity in NP and DP than SP (0.803-and-0.785 vs. 0.712; p < 0.0001). Specificity in NP and DP cases were 4.8% and 2.0% lower than SP cases (0.749 and 0.771 vs. 0.787). The AUC values for NP and DP were significantly higher than SP cases across different levels of breast density (0.814-and-0.820 vs. 0.782; p < 0.0001). The odds ratio (OR) of true positive for NP relative to SP was 1.6 (p < 0.0001) and DP relative to SP was 1.5 (p < 0.0001). Radiologists were more like to detect architectural distortion in DP than SP cases (OR = 3.2; p < 0.0001), whilst the OR for abnormal calcifications was 2.85 (p < 0.0001).

CONCLUSIONS

Cases without previous mammograms or with prior mammograms obtained from different vendors were more likely to benefit radiologists in cancer detection, whilst prior mammograms undertaken from the same vendor were more useful for radiologists in evaluating normal cases.

Look how far we have come: BREAST cancer detection education on the international stage

The development of screening mammography over 30 years has remarkedly reduced breast cancer-associated mortality by 20%-30% through detection of small cancer lesions at early stages. Yet breast screening programmes may function differently in each nation depending on the incidence rate, national legislation, local health infrastructure and training opportunities including feedback on performance. Mammography has been the frontline breast cancer screening tool for several decades; however, it is estimated that there are 15% to 35% of cancers missed on screening which are owing to perceptual and decision-making errors by radiologists and other readers. Furthermore, mammography screening is not available in all countries and the increased speed in the number of new breast cancer cases among less developed countries exceeds that of the developed world in recent decades. Studies conducted through the BreastScreen Reader Assessment Strategy (BREAST) training tools for breast screening readers have documented benchmarking and significant variation in diagnostic performances in screening mammogram test sets in different countries. The performance of the radiologists from less well-established breast screening countries such as China, Mongolia and Vietnam were significant lower in detecting early-stage cancers than radiologists from developed countries such as Australia, USA, Singapore, Italy. Differences in breast features and cancer presentations, discrepancies in the level of experiences in reading screening mammograms, the availability of high-quality national breast screening program and breast image interpretation training courses between developed and less developed countries are likely to have impact on the variation of readers' performances. Hence dedicated education training programs with the ability to tailor to different reader cohorts and different population presentations are suggested to ameliorate challenges in exposure to a range of cancer cases and improve the interpretation skills of local radiologists. Findings from this review provide a good understanding of the radiologist' performances and their improvement using the education interventions, primarily the BREAST program, which has been deployed in a large range of developing and developed countries in the last decade. Self-testing and immediate feedback loops have been shown to have important implications for benchmarking and improving the diagnostic accuracy in radiology worldwide for better breast cancer control.

Computational models of direct and indirect X-ray breast imaging detectors for in silico trials

BACKGROUND

To facilitate in silico studies that investigate digital mammography (DM) and breast tomosynthesis (DBT), models replicating the variety in imaging performance of the DM and DBT systems, observed across manufacturers are needed.

PURPOSE

The main purpose of this work is to develop generic physics models for direct and indirect detector technology used in commercially available systems, with the goal of making them available open source to manufacturers to further tweak and develop the exact in silico replicas of their systems.

METHODS

We recently reported on an in silico version of the SIEMENS Mammomat Inspiration DM/DBT system using an open-source GPU-accelerated Monte Carlo x-ray imaging simulation code (MC-GPU). We build on the previous version of the MC-GPU codes to mimic the imaging performances of two other Food and Drug Administration (FDA)-approved DM/DBT systems, such as Hologic Selenia Dimensions (HSD) and the General Electric Senographe Pristina (GSP) systems. In this work, we developed a hybrid technique to model the optical spread and signal crosstalk observed in the GSP and HSD systems. MC simulations are used to track each x-ray photon till its first interaction within the x-ray detector. On the other hand, the signal spread in the x-ray detectors is modeled using previously developed analytical equations. This approach allows us to preserve the modeling accuracy offered by MC methods in the patient body, while speeding up secondary carrier transport (either electron-hole pairs or optical photons) using analytical equations in the detector. The analytical optical spread model for the indirect detector includes the depth-dependent spread and collection of optical photons and relies on a pre-computed set of point response functions that describe the optical spread as a function of depth. To understand the capabilities of the computational x-ray detector models, we compared image quality metrics like modulation transfer function (MTF), normalized noise power spectrum (NNPS), and detective quantum efficiency (DQE), simulated with our models against measured data. Please note that the purpose of these comparisons with measured data would be to gauge if the model developed as part of this work could replicate commercially used direct and indirect technology in general and not to achieve perfect fits with measured data.

RESULTS

We found that the simulated image quality metrics such as MTF, NNPS, and DQE were in reasonable agreement with experimental data. To demonstrate the imaging performance of the three DM/DBT systems, we integrated the detector models with the VICTRE pipeline and simulated DM images of a fatty breast model containing a spiculated mass and a calcium oxalate cluster. In general, we found that the images generated using the indirect model appeared more blurred with a different noise texture and contrast as compared to the systems with direct detectors.

CONCLUSIONS

We have presented computational models of three commercially available FDA-approved DM/DBT systems, which implement both direct and indirect detector technology. The updated versions of the MC-GPU codes that can be used to replicate three systems are available in open source format through GitHub.

Quantification and Classification of Contrast Enhanced Ultrasound Breast Cancer Data: A Preliminary Study

This study aimed to investigate which of the two frequently adopted perfusion models better describes the contrast enhanced ultrasound (CEUS) perfusion signal in order to produce meaningful imaging markers with the goal of developing a machine-learning model that can classify perfusion curves as benign or malignant in breast cancer data. Twenty-five patients with high suspicion of breast cancer were analyzed with exponentially modified Gaussian (EMG) and gamma variate functions (GVF). The adjusted R² metric was the criterion for assessing model performance. Various classifiers were trained on the quantified perfusion curves in order to classify the curves as benign or malignant on a voxel basis. Sensitivity, specificity, geometric mean, and AUROC were the validation metrics. The best quantification model was EMG with an adjusted R² of 0.60 ± 0.26 compared to 0.56 ± 0.25 for GVF. Logistic regression was the classifier with the highest performance (sensitivity, specificity, G_mean, and AUROC = 89.2 ± 10.7, 70.0 ± 18.5, 77.1 ± 8.6, and 91.0 ± 6.6, respectively). This classification method obtained similar results that are consistent with the current literature. Breast cancer patients can benefit from early detection and characterization prior to biopsy.

OUP accepted manuscript

In screening for breast cancer (BC), mammographic breast density (MBD) is a powerful risk factor that increases breast carcinogenesis and synergistically reduces the sensitivity of mammography. It also reduces specificity of lesion identification, leading to recalls, additional testing, and delayed and later-stage diagnoses, which result in increased health care costs. These findings provide the foundation for dense breast notification laws and lead to the increase in patient and provider interest in MBD. However, unlike other risk factors for BC, MBD is dynamic through a woman’s lifetime and is modifiable. Although MBD is known to change as a result of factors such as reproductive history and hormonal status, few conclusions have been reached for lifestyle factors such as alcohol, diet, physical activity, smoking, body mass index (BMI), and some commonly used medications. Our review examines the emerging evidence for the association of modifiable factors on MBD and the influence of MBD on BC risk. There are clear associations between alcohol use and menopausal hormone therapy and increased MBD. Physical activity and the Mediterranean diet lower the risk of BC without significant effect on MBD. Although high BMI and smoking are known risk factors for BC, they have been found to decrease MBD. The influence of several other factors, including caffeine intake, nonhormonal medications, and vitamins, on MBD is unclear. We recommend counseling patients on these modifiable risk factors and using this knowledge to help with informed decision making for tailored BC prevention strategies.

Cumulative risk of a false-positive screening result: A retrospective cohort study using empirical data from 10 biennial screening rounds in BreastScreen Norway

BACKGROUND

False-positive screening results are an inevitable and commonly recognized disadvantage of mammographic screening. This study estimated the cumulative probability of experiencing a first false-positive screening result in women attending 10 biennial screening rounds in BreastScreen Norway, which targets women aged 50 to 69 years.

METHODS

This retrospective cohort study analyzed screening outcomes from 421,545 women who underwent 1,894,523 screening examinations during 1995-2019. Empirical data were used to calculate the cumulative risk of experiencing a first false-positive screening result and a first false-positive screening result that involved an invasive procedure over 10 screening rounds. Logistic regression was used to evaluate the effect of adjusting for irregular attendance, age at screening, and number of screens attended.

RESULTS

The cumulative risk of experiencing a first false-positive screening result was 18.04% (95% confidence interval [CI], 18.00%-18.07%). It was 5.01% (95% CI, 5.01%-5.02%) for experiencing a false-positive screening result that involved an invasive procedure. Adjusting for irregular attendance or age at screening did not appreciably affect these estimates. After adjustments for the number of screens attended, the cumulative risk of a first false-positive screening result was 18.28% (95% CI, 18.24%-18.32%), and the risk of a false-positive screening result including an invasive procedure was 5.11% (95% CI, 5.11%-5.22%). This suggested that there was minimal bias from dependent censoring.

CONCLUSIONS

Nearly 1 in 5 women will experience a false-positive screening result if they attend 10 biennial screening rounds in BreastScreen Norway. One in 20 will experience a false-positive screening result with an invasive procedure.

LAY SUMMARY

A false-positive screening result occurs when a woman attending mammographic screening is called back for further assessment because of suspicious findings, but the assessment does not detect breast cancer. Further assessment includes additional imaging. Usually, it involves ultrasound, and sometimes, it involves a biopsy. This study has evaluated the chance of experiencing a false-positive screening result among women attending 10 screening examinations over 20 years in BreastScreen Norway. Nearly 1 in 5 women will experience a false-positive screening result over 10 screening rounds. One in 20 women will experience a false-positive screening result involving a biopsy.

Circulating cell-free DNA-based methylation patterns for breast cancer diagnosis

Mammography is used to detect breast cancer (BC), but its sensitivity is limited, especially for dense breasts. Circulating cell-free DNA (cfDNA) methylation tests is expected to compensate for the deficiency of mammography. We derived a specific panel of markers based on computational analysis of the DNA methylation profiles from The Cancer Genome Atlas (TCGA). Through training (n = 160) and validation set (n = 69), we developed a diagnostic prediction model with 26 markers, which yielded a sensitivity of 89.37% and a specificity of 100% for differentiating malignant disease from normal lesions [AUROC = 0.9816 (95% CI: 96.09-100%), and AUPRC = 0.9704 (95% CI: 94.54–99.46%)]. A simplified 4-marker model including cg23035715, cg16304215, cg20072171, and cg21501525 had a similar diagnostic power [AUROC = 0.9796 (95% CI: 95.56–100%), and AUPRC = 0.9220 (95% CI: 91.02–94.37%)]. We found that a single cfDNA methylation marker, cg23035715, has a high diagnostic power [AUROC = 0.9395 (95% CI: 89.72–99.27%), and AUPRC = 0.9111 (95% CI: 88.45–93.76%)], with a sensitivity of 84.90% and a specificity of 93.88%. In an independent testing dataset (n = 104), the obtained diagnostic prediction model discriminated BC patients from normal controls with high accuracy [AUROC = 0.9449 (95% CI: 90.07–98.91%), and AUPRC = 0.8640 (95% CI: 82.82–89.98%)]. We compared the diagnostic power of cfDNA methylation and mammography. Our model yielded a sensitivity of 94.79% (95% CI: 78.72–97.87%) and a specificity of 98.70% (95% CI: 86.36–100%) for differentiating malignant disease from normal lesions [AUROC = 0.9815 (95% CI: 96.75–99.55%), and AUPRC = 0.9800 (95% CI: 96.6–99.4%)], with better diagnostic power and had better diagnostic power than that of using mammography [AUROC = 0.9315 (95% CI: 89.95–96.34%), and AUPRC = 0.9490 (95% CI: 91.7–98.1%)]. In addition, hypermethylation profiling provided insights into lymph node metastasis stratifications (p < 0.05). In conclusion, we developed and tested a cfDNA methylation model for BC diagnosis with better performance than mammography.

Function-related Indicators and Outcomes of Screening Mammography in Older Women: Evidence from the Breast Cancer Surveillance Consortium Cohort

BACKGROUND

Previous reports suggested risk of death and breast cancer varied by comorbidity and age in older women undergoing mammography. However, impacts of functional limitations remain unclear.

METHODS

We used data from 238,849 women in the Breast Cancer Surveillance Consortium-Medicare linked database (1999-2015) who had screening mammogram at ages 66-94 years. We estimated risk of breast cancer, breast cancer death, and non-breast cancer death by function-related indicator (FRI) which incorporated 16 claims-based items and was categorized as an ordinal variable (0, 1, and 2+). Fine and Gray proportional sub-distribution hazards models were applied with breast cancer and death treated as competing events. Risk estimates by FRI scores were adjusted by age and NCI comorbidity index separately and stratified by these factors.

RESULTS

Overall, 9,252 women were diagnosed with breast cancer, 406 died of breast cancer, and 41,640 died from non-breast cancer causes. The 10-year age-adjusted invasive breast cancer risk slightly decreased with FRI score [FRI = 0: 4.0%, 95% confidence interval (CI) = 3.8-4.1; FRI = 1: 3.9%, 95% CI = 3.7-4.2; FRI ≥ 2: 3.5%, 95% CI = 3.1-3.9). Risk of non-breast cancer death increased with FRI score (FRI = 0: 18.8%, 95% CI = 18.5-19.1; FRI = 1: 24.4%, 95% CI = 23.9-25.0; FRI ≥ 2: 39.8%, 95% CI = 38.8-40.9]. Risk of breast cancer death was low with minimal differences across FRI scores. NCI comorbidity index-adjusted models and stratified analyses yielded similar patterns.

CONCLUSIONS

Risk of non-breast cancer death substantially increases with FRI score, whereas risk of breast cancer death is low regardless of functional status.

IMPACT

Older women with functional limitations should be informed that they may not benefit from screening mammography.

Quantitative STAU2 measurement in lymphocytes for breast cancer risk assessment

Although mammograms play a key role in early breast cancer detection, the test is not applicable to all women, for example, women under the age of 40. The development of a noninvasive blood test with high sensitivity and accessibility will improve the effectiveness of breast cancer screening programmes. Secretory factors released from cancer cells can induce the expression of certain genes in a large number of white blood cells (WBCs). Therefore, cancer-dependent proteins in WBCs can be used as tumour markers with high sensitivity. Five proteins (LMAN1, AZI2, STAU2, MMP9 and PLOD1) from a systemic analysis of a variety of array data of breast cancer patients were subjected to immunofluorescence staining to evaluate the presence of fixed WBCs on 96-well plates from 363 healthy females and 358 female breast cancer patients. The results revealed that the average fluorescence intensity of anti-STAU2 and the percentage of STAU2-positive T and B lymphocytes in breast cancer patients (110.50 ± 23.38 and 61.87 ± 12.44, respectively) were significantly increased compared with those in healthy females (56.47 ± 32.03 and 33.02 ± 18.10, respectively) (p = 3.56 × 10^-71, odds ratio = 24.59, 95% CI = 16.64-36.34). The effect of secreted molecules from breast cancer cells was proven by the increase in STAU2 intensity in PBMCs cocultured with MCF-7 and T47D cells at 48 h (p = 0.0289). The test demonstrated 98.32%, 82.96%, and 48.32% sensitivity and 56.47%, 83.47%, and 98.62% specificity in correlation with the percentage of STAU2-positive cells at 40, 53.34 and 63.38, respectively. We also demonstrated how to use the STAU2 test for the assessment of risk in women under the age of 40. STAU2 is a novel breast cancer marker that can be assessed by quantitative immunofluorescence staining of fixed WBCs that are transportable at room temperature via mail, representing a useful risk assessment tool for women without access to mammograms.

Identification of Novel Diagnostic Biomarkers in Breast Cancer Using Targeted Metabolomic Profiling

INTRODUCTION

Breast cancer (BC) is the most common cancer in women, with a high disease burden, especially in the advanced disease stages. Our study investigated the metabolomic profile of breast cancer patients' serum with the aim of identifying novel diagnostic biomarkers that could be used, especially for early disease detection.

MATERIALS AND METHODS

Using targeted metabolomic serum profiling based on high-performance liquid chromatography mass spectrometry, women with BC (n = 39) and a control group (n = 21) were examined for 232 endogenous metabolites.

RESULTS

The top performing biomarkers included acylcarnitines (ACs) and 9,12-linoleic acid. A combined panel of the top 4 biomarkers achieved 83% sensitivity and 81% specificity, with an area under the curve (AUC) of 0.839 (95% confidence interval, 0.811-0.867). Individual markers also provided significant predictive values: AC 12:0, sensitivity of 72%, specificity of 67%, and AUC of 0.71; AC 14:2, sensitivity of 74%, specificity of 71%, and AUC of 0.73; AC 14:0: sensitivity of 67%, specificity of 81%, and AUC of 0.73; and 9,12-linoleic acid, sensitivity of 69%, specificity of 67%, and AUC of 0.71. The individual markers, however, did not reach the high sensitivity and specificity of the 4-biomarker combination.

CONCLUSION

Using mass spectrometry-targeted metabolomic profiling, ACs and 9,12-linoleic acid were identified as potential diagnostic biomarkers for breast cancer. Additionally, these identified metabolites could provide additional insight into cancer cell metabolism.

Genetic Testing and Screening Recommendations for Patients with Hereditary Breast Cancer

Professionals who specialize in breast imaging may be the first to initiate the conversation about genetic counseling with patients who have a diagnosis of premenopausal breast cancer or a strong family history of breast and ovarian cancer. Commercial genetic testing panels have gained popularity and have become more affordable in recent years. Therefore, it is imperative for radiologists to be able to provide counseling and to identify those patients who should be referred for genetic testing. The authors review the process of genetic counseling and the associated screening recommendations for patients at high and moderate risk. Ultimately, genetic test results enable appropriate patient-specific screening, which allows improvement of overall survival by early detection and timely treatment. The authors discuss pretest counseling, which involves the use of various breast cancer risk assessment tools such as the Gail and Tyrer-Cuzick models. The most common high- and moderate-risk gene mutations associated with breast cancer are also reviewed. In addition to BRCA1 and BRCA2, several high-risk genes, including TP53, PTEN, CDH1, and STK11, are discussed. Moderate-risk genes include ATM, CHEK2, and PALB2. The imaging appearances of breast cancer typically associated with each gene mutation, as well as the other associated cancers, are described. ^©RSNA, 2020 See discussion on this article by Butler (pp 937-940).

"The unusual suspects"-Mammographic, sonographic, and histopathologic appearance of atypical breast masses

Breast malignancy is the second most common cause of cancer death in women. However, less common breast masses can mimic carcinoma and can pose diagnostic challenges. This case-based review describes a spectrum of rare breast neoplastic and non-neoplastic masses ranging from malignant to benign entities. Malignant masses in this review include adenoid cystic carcinoma, spindle cell lipoma, granular cell tumor, angiosarcoma, glomus tumor, adenosquamous carcinoma, and myofibroblastoma. Benign masses include sarcoidosis, diabetic mastopathy, and cat scratch disease. Demographics and, when relevant, clinical presentation are summarized. Breast imaging appearance on mammography and ultrasound are highlighted along with radiology-pathology correlation with the appearance and characteristics of the histopathological specimen of these rare masses.

DNA Methylation-Based Testing in Liquid Biopsies as Detection and Prognostic Biomarkers for the Four Major Cancer Types

Lung, breast, colorectal, and prostate cancers are the most incident worldwide. Optimal population-based cancer screening methods remain an unmet need, since cancer detection at early stages increases the prospects of successful and curative treatment, leading to a lower incidence of recurrences. Moreover, the current parameters for cancer patients’ stratification have been associated with divergent outcomes. Therefore, new biomarkers that could aid in cancer detection and prognosis, preferably detected by minimally invasive methods are of major importance. Aberrant DNA methylation is an early event in cancer development and may be detected in circulating cell-free DNA (ccfDNA), constituting a valuable cancer biomarker. Furthermore, DNA methylation is a stable alteration that can be easily and rapidly quantified by methylation-specific PCR methods. Thus, the main goal of this review is to provide an overview of the most important studies that report methylation biomarkers for the detection and prognosis of the four major cancers after a critical analysis of the available literature. DNA methylation-based biomarkers show promise for cancer detection and management, with some studies describing a “PanCancer” detection approach for the simultaneous detection of several cancer types. Nonetheless, DNA methylation biomarkers still lack large-scale validation, precluding implementation in clinical practice.

Sensitivity of screening mammography by density and texture: a cohort study from a population-based screening program in Denmark

Background

Screening mammography works better in fatty than in dense breast tissue. Computerized assessment of parenchymal texture is a non-subjective method to obtain a refined description of breast tissue, potentially valuable in addition to breast density scoring for the identification of women in need of supplementary imaging. We studied the sensitivity of screening mammography by a combination of radiologist-assessed Breast Imaging Reporting and Data System (BI-RADS) density score and computer-assessed parenchymal texture marker, mammography texture resemblance (MTR), in a population-based screening program.

Methods

Breast density was coded according to the fourth edition of the BI-RADS density code, and MTR marker was divided into quartiles from 1 to 4. Screening data were followed up for the identification of screen-detected and interval cancers. We calculated sensitivity and specificity with 95% confidence intervals (CI) by BI-RADS density score, MTR marker, and combination hereof.

Results

Density and texture were strongly correlated, but the combination led to the identification of subgroups with different sensitivity. Sensitivity was high, about 80%, in women with BI-RADS density score 1 and MTR markers 1 or 2. Sensitivity was low, 67%, in women with BI-RADS density score 2 and MTR marker 4. For women with BI-RADS density scores 3 and 4, the already low sensitivity was further decreased for women with MTR marker 4. Specificity was 97–99% in all subgroups.

Conclusion

Our study showed that women with low density constituted a heterogenous group. Classifying women for extra imaging based on density only might be a too crude approach. Screening sensitivity was systematically high in women with fatty and homogenous breast tissue.

Cost- Effectiveness of Mammography Screening Program in a Resource-Limited Post-Soviet Country of Kazakhstan

OBJECTIVES

To conduct cost effectiveness and benefit-cost analyses of the organized mammography-screening program in the Republic of Kazakhstan comparing women who developed breast cancer in screened and unscreened scenario.

METHODS

389,352 screened women were included in the study. Among these, 895 women were further diagnosed with breast cancer. Outcomes measures include life years saved, quality-adjusted life years, incremental cost-effectiveness ratio, and value of statistical life year. Sensitivity analyses were performed to assess uncertainty.

RESULTS

Compared to no screening scenario, an organized mammography yielded an additional 1,253 life years and 790 quality-adjusted life years in 2016. The incremental cost-effectiveness ratio was equal to 3,157 USD per one QALY saved, which is two times less than the GDP per capita in Kazakhstan in 2016. Sensitivity analysis showed that the mammography remains cost-effective in the majority of the scenarios.

CONCLUSION

Mammography screening in Kazakhstan was found to be highly cost-effective, associated with treatment cost savings, and can be an efficient use of limited resources in Kazakhstan.

Five-Year Overall Survival of Interval Breast Cancers is Better than Non- Interval Cancers from Korean Breast Cancer Registry

Objective: Interval breast cancer (IC) is a limitation of breast cancer screening. We investigated data from a large scaled breast cancer dataset of patients with breast cancer who underwent breast cancer screening in order to recapitulate the overall survival (OS) of patients with ICs compared to those with non-ICs. Methods: A total of 27,141 patients in the Korean breast cancer registry with breast cancer who had ever participated in biannual national breast cancer screening programs between 2009 and 2013 were enrolled. We compared the social, pregnancy-associated, and pathologic characteristics between the IC and non-IC groups and identified the significant prognostic factors for OS. Results: The proportion of ICs was 1.3% (370/27,141) in this study population. ICs were correlated with age 45-55 years at diagnosis, higher levels of education, early menopause (<50 years), hormone replacement therapy, specific provinces (Kangwon, Kyungnam, Jeju, and Dae-jeon), and family history of breast cancer. Low-to-intermediate nuclear grade, early stage (stage 0-I), and low Ki-67 level were also correlated with IC proportion. Non-ICs were associated with an increased risk of five-year mortality (hazard ratio [HR] 7.4; 95% confidence interval [CI]:1.85-29.66; p = 0.005) compared to ICs. Lymph node metastasis, residence (Kyung-nam province), low education status, high histologic grade, and asymptomatic cancers increased the HR of five-year OS. Conclusion: ICs occurred unequally in specific province and relatively high-educated women in Korea. They were also diagnosed with early-stage breast cancer with a favorable recurrence risk, and their outcome was better than those of patients with other breast cancers in breast cancer screening.

Can eye-tracking metrics be used to better pair radiologists in a mammogram reading task?

PURPOSE

To propose a framework for optimal pairing of radiologists when reading mammograms based on their search patterns.

MATERIALS AND METHODS

Four experienced and four less-experienced radiologists were asked to assess 120 cases (59 with cancers) while their eye positions were tracked. Fourteen eye-tracking metrics were extracted to quantify the differences among radiologists' visual search pattern. For each radiologist and metric, less-experienced radiologists and expert readers were ranked based on the level of similarities in gaze patterns (from the most different to the most similar). Less-experienced readers and experts were also ranked based on the values of area under the receiver operating characteristic curve (AUC) after pairing (the best possible way of ranking). Using the Kendall's tau distance, rankings based on different metrics were compared with the best possible ranking. Using paired Wilcoxon signed-rank test, the AUC values when pairing in the best way were compared with pairing based on different metrics. Finally, we investigated the robustness of pairing strategies against the small sample size.

RESULTS

For ranking the experienced radiologists, results from eight metrics were as good as the best possible ranking. For the less-experienced ones, only one metric resulted in a ranking comparable to the best possible way of ranking. The AUC values of pairings based on these metrics did not differ significantly from the best pairing scenario. Compared to the pairings based on the cognitive metrics, the ranking based on AUC values varied more greatly with the sample size, suggesting that it is less robust against the small sample size compared to the cognitive metrics.

CONCLUSION

Different pairings may have different effects on performance; some are detrimental while some improve the performance of the pair. Using the suggested cognitive metrics, we can optimize the pairings even with a small dataset.

Patient, Radiologist, and Examination Characteristics Affecting Screening Mammography Recall Rates in a Large Academic Practice

OBJECTIVE

The aims of this study were to evaluate patient, radiologist, and examination characteristics affecting screening mammography recall rates in an academic breast imaging practice and to identify modifiable factors that could reduce recall variation.

METHODS

This institutional review board-approved retrospective study included screening mammographic examinations in female patients interpreted by 13 breast imaging specialists at an academic center and two outpatient centers from October 1, 2012, to May 31, 2015. Patient demographics were extracted via electronic medical record. Natural language processing captured breast density, BI-RADS assignment, and current and prior screening examination findings. Radiologists' annual screening volumes, clinical experience, and concentration in breast imaging were calculated. Risk aversion, stress from uncertainty, and malpractice concerns were derived via survey. Univariate and multivariate analyses assessed patient, radiologist, and examination characteristics associated with likelihood of mammography recall. The Pearson product-moment correlation coefficient was used to assess the relationship between cancer detection rate and recall rate.

RESULTS

Overall, 5,678 of 61,198 screening examinations (9.3%) were recalled. In multivariate analysis, patient and radiologist characteristics associated with higher odds of recall included patient's age < 50 years (P < .0001), prior mammographic findings (calcification [P < .0001], mass [P < .0001], higher density category [P < .0001]), baseline examination (P < .0001), annual reading volume < 1,250 examinations (P = .0282), and <10 years of experience (P = .0036). Radiologist's risk aversion, stress from uncertainty, malpractice concerns, and cancer detection rates were not associated with higher recall rates (r = -0.36, P = .23).

CONCLUSIONS

In addition to patient and examination factors, screening recall variations were associated with radiologists' annual reading volume and experience. Interventions targeting radiologist factors (screening volumes, second review of potential recalls) may help reduce unwarranted variation in screening recall.

Insights Into Breast Cancer Screening: A Computer Simulation of Two Contemporary Screening Strategies

OBJECTIVE

The debate over the value of screening mammography is rekindled with each new published study or guideline. Central to the discussion are the uncertainties about screening benefits and harms and the criteria used to assess them. Today, the magnitude of benefits for a population is less certain, and the evolving concept of harm has come to encompass false-positives (FPs), unnecessary biopsies, overdiagnosis, and overtreatment. This study uses a Monte Carlo computer simulation to study the balance of benefits and harms of mammographic breast cancer screening for average-risk women.

MATERIALS AND METHODS

This investigation compares the American Cancer Society's 2015 mixed annual-biennial guideline with the U.S. Preventive Services Task Force's 2016 fixed biennial guideline. Screening strategies are compared using cost-effectiveness acceptability curves, an economic analysis describing uncertainty in evaluating costs and health outcomes. Strategy preference is examined under changing assumptions of willingness to pay for a quality-adjusted life-year. Additionally, comparative effectiveness analysis is performed using FP screens and unnecessary biopsies per life-year gained. Alternative scenarios are compared assuming a reduced mortality benefit of screening.

RESULTS

In general, results using both cost-effectiveness and clinical measures indicate that American Cancer Society's 2015 mixed annual-biennial guideline is preferred. Assuming decreases in the mortality benefit of mammography, no screening may be reasonable.

CONCLUSION

The use of a mixed annual-biennial strategy for population screening takes advantage of the nonuniformity of occurrence of mammography benefits and harms over the duration of screening. This approach represents a step toward improving guidelines by exploiting age dependencies at which benefits and harms accrue.

BRCA-associated Cancers: Role of Imaging in Screening, Diagnosis, and Management

Harmful mutations of the BRCA tumor suppressor genes result in a greater lifetime risk for malignancy-breast and ovarian cancers in particular. An increased risk for male breast, fallopian tube, primary peritoneal, pancreatic, prostate, and colon cancers also has been reported. The BRCA gene is inherited in an autosomal dominant pattern and tends to be highly penetrant; thus, there is an increased incidence of these cancers in affected families. Compared with sporadic tumors, BRCA-associated malignancies have unique manifestations, clinical features, and pathologic profiles. Manifestation at an early patient age, high-grade tumors, and an aggressive clinical course are common features of BRCA-associated malignancies. Understanding the behavior of these cancers aids in identification of affected individuals and families, who can then make informed decisions regarding their future health. Enhanced screening, prophylactic surgery, and chemoprevention are options for managing cancer risk factors in these individuals. Imaging has an important role in the screening, evaluation, staging, and follow-up of BRCA-associated malignancies. Supplemental screening of BRCA mutation carriers often begins at an early age and is critical for early and accurate cancer diagnoses. The authors review the etiopathogenesis and imaging features of BRCA-associated malignancies, the importance of a multidisciplinary approach to determining the diagnosis, and the treatment of patients who have these mutations to improve their outcomes. ^© RSNA, 2017.

Breast Cancer Screening Programmes across the WHO European Region: Differences among Countries Based on National Income Level

Breast cancer (BC) is the most frequent tumour affecting women all over the world. In low- and middle-income countries, where its incidence is expected to rise further, BC seems set to become a public health emergency. The aim of the present study is to provide a systematic review of current BC screening programmes in WHO European Region to identify possible patterns. Multiple correspondence analysis was performed to evaluate the association among: measures of occurrence; GNI level; type of BC screening programme; organization of public information and awareness campaigns regarding primary prevention of modifiable risk factors; type of BC screening services; year of screening institution; screening coverage and data quality. A key difference between High Income (HI) and Low and Middle Income (LMI) States, emerging from the present data, is that in the former screening programmes are well organized, with approved screening centres, the presence of mobile units to increase coverage, the offer of screening tests free of charge; the fairly high quality of occurrence data based on high-quality sources, and the adoption of accurate methods to estimate incidence and mortality. In conclusion, the governments of LMI countries should allocate sufficient resources to increase screening participation and they should improve the accuracy of incidence and mortality rates.

National Performance Benchmarks for Modern Diagnostic Digital Mammography: Update from the Breast Cancer Surveillance Consortium

Purpose To establish contemporary performance benchmarks for diagnostic digital mammography with use of recent data from the Breast Cancer Surveillance Consortium (BCSC). Materials and Methods Institutional review board approval was obtained for active or passive consenting processes or to obtain a waiver of consent to enroll participants, link data, and perform analyses. Data were obtained from six BCSC registries (418 radiologists, 92 radiology facilities). Mammogram indication and assessments were prospectively collected for women undergoing diagnostic digital mammography and linked with cancer diagnoses from state cancer registries. The study included 401 548 examinations conducted from 2007 to 2013 in 265 360 women. Results Overall diagnostic performance measures were as follows: cancer detection rate, 34.7 per 1000 (95% confidence interval [CI]: 34.1, 35.2); abnormal interpretation rate, 12.6% (95% CI: 12.5%, 12.7%); positive predictive value (PPV) of a biopsy recommendation (PPV₂), 27.5% (95% CI: 27.1%, 27.9%); PPV of biopsies performed (PPV₃), 30.4% (95% CI: 29.9%, 30.9%); false-negative rate, 4.8 per 1000 (95% CI: 4.6, 5.0); sensitivity, 87.8% (95% CI: 87.3%, 88.4%); and specificity, 90.5% (95% CI: 90.4%, 90.6%). Among cancers detected, 63.4% were stage 0 or 1 cancers, 45.6% were minimal cancers, the mean size of invasive cancers was 21.2 mm, and 69.6% of invasive cancers were node negative. Performance metrics varied widely across diagnostic indications, with cancer detection rate (64.5 per 1000) and abnormal interpretation rate (18.7%) highest for diagnostic mammograms obtained to evaluate a breast problem with a lump. Compared with performance during the screen-film mammography era, diagnostic digital performance showed increased abnormal interpretation and cancer detection rates and decreasing PPVs, with less than 70% of radiologists within acceptable ranges for PPV₂ and PPV₃. Conclusion These performance measures can serve as national benchmarks that may help transform the marked variation in radiologists' diagnostic performance into targeted quality improvement efforts. ^© RSNA, 2017 Online supplemental material is available for this article.

Volumetric breast density affects performance of digital screening mammography

PURPOSE

To determine to what extent automatically measured volumetric mammographic density influences screening performance when using digital mammography (DM).

METHODS

We collected a consecutive series of 111,898 DM examinations (2003-2011) from one screening unit of the Dutch biennial screening program (age 50-75 years). Volumetric mammographic density was automatically assessed using Volpara. We determined screening performance measures for four density categories comparable to the American College of Radiology (ACR) breast density categories.

RESULTS

Of all the examinations, 21.6% were categorized as density category 1 ('almost entirely fatty') and 41.5, 28.9, and 8.0% as category 2-4 ('extremely dense'), respectively. We identified 667 screen-detected and 234 interval cancers. Interval cancer rates were 0.7, 1.9, 2.9, and 4.4‰ and false positive rates were 11.2, 15.1, 18.2, and 23.8‰ for categories 1-4, respectively (both p-trend < 0.001). The screening sensitivity, calculated as the proportion of screen-detected among the total of screen-detected and interval tumors, was lower in higher density categories: 85.7, 77.6, 69.5, and 61.0% for categories 1-4, respectively (p-trend < 0.001).

CONCLUSIONS

Volumetric mammographic density, automatically measured on digital mammograms, impacts screening performance measures along the same patterns as established with ACR breast density categories. Since measuring breast density fully automatically has much higher reproducibility than visual assessment, this automatic method could help with implementing density-based supplemental screening.

Circulating cell-free DNA-based epigenetic assay can detect early breast cancer

Background

Circulating cell-free DNA (cfDNA) has recently been recognized as a resource for biomarkers of cancer progression, treatment response, and drug resistance. However, few have demonstrated the usefulness of cfDNA for early detection of cancer. Although aberrant DNA methylation in cfDNA has been reported for more than a decade, its diagnostic accuracy remains unsatisfactory for cancer screening. Thus, the aim of the present study was to develop a highly sensitive cfDNA-based system for detection of primary breast cancer (BC) using epigenetic biomarkers and digital PCR technology.

Methods

Array-based genome-wide DNA methylation analysis was performed using 56 microdissected breast tissue specimens, 34 cell lines, and 29 blood samples from healthy volunteers (HVs). Epigenetic markers for BC detection were selected, and a droplet digital methylation-specific PCR (ddMSP) panel with the selected markers was established. The detection model was constructed by support vector machine and evaluated using cfDNA samples.

Results

The methylation array analysis identified 12 novel epigenetic markers (JAK3, RASGRF1, CPXM1, SHF, DNM3, CAV2, HOXA10, B3GNT5, ST3GAL6, DACH1, P2RX3, and chr8:23572595) for detecting BC. We also selected four internal control markers (CREM, GLYATL3, ELMOD3, and KLF9) that were identified as infrequently altered genes using a public database. A ddMSP panel using these 16 markers was developed and detection models were constructed with a training dataset containing cfDNA samples from 80 HVs and 87 cancer patients. The best detection model adopted four methylation markers (RASGRF1, CPXM1, HOXA10, and DACH1) and two parameters (cfDNA concentration and the mean of 12 methylation markers), and, and was validated in an independent dataset of 53 HVs and 58 BC patients. The area under the receiver operating characteristic curve for cancer-normal discrimination was 0.916 and 0.876 in the training and validation dataset, respectively. The sensitivity and the specificity of the model was 0.862 (stages 0-I 0.846, IIA 0.862, IIB-III 0.818, metastatic BC 0.935) and 0.827, respectively.

Conclusion

Our epigenetic-marker-based system distinguished BC patients from HVs with high accuracy. As detection of early BC using this system was comparable with that of mammography screening, this system would be beneficial as an optional method of screening for BC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-016-0788-z) contains supplementary material, which is available to authorized users.

Retrospective observation on contribution and limitations of screening for breast cancer with mammography in Korea: detection rate of breast cancer and incidence rate of interval cancer of the breast

Background

The purpose of this study was to determine the benefits and limitations of screening for breast cancer using mammography.

Methods

Descriptive design with follow-up was used in the study. Data from breast cancer screening and health insurance claim data were used. The study population consisted of all participants in breast cancer screening from 2009 to 2014. Crude detection rate, positive predictive value and sensitivity and specificity of breast cancer screening and, incidence rate of interval cancer of the breast were calculated.

Results

The crude detection rate of breast cancer screening per 100,000 participants increased from 126.3 in 2009 to 182.1 in 2014. The positive predictive value of breast cancer screening per 100,000 positives increased from 741.2 in 2009 to 1,367.9 in 2014. The incidence rate of interval cancer of the breast per 100,000 negatives increased from 51.7 in 2009 to 76.3 in 2014. The sensitivities of screening for breast cancer were 74.6% in 2009 and 75.1% in 2014 and the specificities were 83.1% in 2009 and 85.7% in 2014.

Conclusions

To increase the detection rate of breast cancer by breast cancer screening using mammography, the participation rate should be higher and an environment where accurate mammography and reading can be performed and reinforcement of quality control are required. To reduce the incidence rate of interval cancer of the breast, it will be necessary to educate women after their 20s to perform self-examination of the breast once a month regardless of participation in screening for breast cancer.

Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey

Abstract

EUSOBI and 30 national breast radiology bodies support mammography for population-based screening, demonstrated to reduce breast cancer (BC) mortality and treatment impact. According to the International Agency for Research on Cancer, the reduction in mortality is 40 % for women aged 50–69 years taking up the invitation while the probability of false-positive needle biopsy is <1 % per round and overdiagnosis is only 1–10 % for a 20-year screening. Mortality reduction was also observed for the age groups 40–49 years and 70–74 years, although with “limited evidence”. Thus, we firstly recommend biennial screening mammography for average-risk women aged 50–69 years; extension up to 73 or 75 years, biennially, is a second priority, from 40–45 to 49 years, annually, a third priority. Screening with thermography or other optical tools as alternatives to mammography is discouraged. Preference should be given to population screening programmes on a territorial basis, with double reading. Adoption of digital mammography (not film-screen or phosphor-plate computer radiography) is a priority, which also improves sensitivity in dense breasts. Radiologists qualified as screening readers should be involved in programmes. Digital breast tomosynthesis is also set to become “routine mammography” in the screening setting in the next future. Dedicated pathways for high-risk women offering breast MRI according to national or international guidelines and recommendations are encouraged.

Key points

• EUSOBI and 30 national breast radiology bodies support screening mammography.

• A first priority is double-reading biennial mammography for women aged 50–69 years.

• Extension to 73–75 and from 40–45 to 49 years is also encouraged.

• Digital mammography (not film-screen or computer radiography) should be used.

• DBT is set to become “routine mammography” in the screening setting in the next future.

Population-based screening for cancer: hope and hype

Several important lessons have been learnt from our experiences in screening for various cancers. Screening programmes for cervical and colorectal cancers have had the greatest success, probably because these cancers are relatively homogenous, slow-growing, and have identifiable precursors that can be detected and removed; however, identifying the true obligate precursors of invasive disease remains a challenge. With regard to screening for breast cancer and for prostate cancer, which focus on early detection of invasive cancer, preferential detection of slower-growing, localized cancers has occurred, which has led to concerns about overdiagnosis and overtreatment; programmes for early detection of invasive lung cancers are emerging, and have faced similar challenges. A crucial consideration in screening for breast, prostate, and lung cancers is their remarkable phenotypic heterogeneity, ranging from indolent to highly aggressive. Efforts have been made to address the limitations of cancer-screening programmes, providing an opportunity for cross-disciplinary learning and further advancement of the science. Current innovations are aimed at identifying the individuals who are most likely to benefit from screening, increasing the yield of consequential cancers on screening and biopsy, and using molecular tests to improve our understanding of disease biology and to tailor treatment. We discuss each of these concepts and outline a dynamic framework for continuous improvements in the field of cancer screening.

Antibody-Guided In Vivo Imaging for Early Detection of Mammary Gland Tumors

BACKGROUND: Earlier detection of transformed cells using target-specific imaging techniques holds great promise. We have developed TAB 004, a monoclonal antibody highly specific to a protein sequence accessible in the tumor form of MUC1 (tMUC1). We present data assessing both the specificity and sensitivity of TAB 004 in vitro and in genetically engineered mice in vivo. METHODS: Polyoma Middle T Antigen mice were crossed to the human MUC1.Tg mice to generate MMT mice. In MMT mice, mammary gland hyperplasia is observed between 6 and 10 weeks of age that progresses to ductal carcinoma in situ by 12 to 14 weeks and adenocarcinoma by 18 to 24 weeks. Approximately 40% of these mice develop metastasis to the lung and other organs with a tumor evolution that closely mimics human breast cancer progression. Tumor progression was monitored in MMT mice (from ages 8 to 22 weeks) by in vivo imaging following retro-orbital injections of the TAB 004 conjugated to indocyanine green (TAB-ICG). At euthanasia, mammary gland tumors and normal epithelial tissues were collected for further analyses. RESULTS: In vivo imaging following TAB-ICG injection permitted significantly earlier detection of tumors compared with physical examination. Furthermore, TAB-ICG administration in MMT mice enabled the detection of lung metastases while sparing recognition of normal epithelia. CONCLUSIONS: The data highlight the specificity and the sensitivity of the TAB 004 antibody in differentiating normal versus tumor form of MUC1 and its utility as a targeted imaging agent for early detection, tumor monitoring response, as well as potential clinical use for targeted drug delivery.

Experimental feasibility of multistatic holography for breast microwave radar image reconstruction

PURPOSE

The goal of this study was to assess the experimental feasibility of circular multistatic holography, a novel breast microwave radar reconstruction approach, using experimental datasets recorded using a preclinical experimental setup. The performance of this approach was quantitatively evaluated by calculating the signal to clutter ratio (SCR), contrast to clutter ratio (CCR), tumor to fibroglandular response ratio (TFRR), spatial accuracy, and reconstruction time.

METHODS

Five datasets were recorded using synthetic phantoms with the dielectric properties of breast tissue in the 1-6 GHz range using a custom radar system developed by the authors. The datasets contained synthetic structures that mimic the dielectric properties of fibroglandular breast tissues. Four of these datasets the authors covered an 8 mm inclusion that emulated a tumor. A custom microwave radar system developed at the University of Manitoba was used to record the radar responses from the phantoms. The datasets were reconstructed using the proposed multistatic approach as well as with a monostatic holography approach that has been previously shown to yield the images with the highest contrast and focal quality.

RESULTS

For all reconstructions, the location of the synthetic tumors in the experimental setup was consistent with the position in the both the monostatic and multistatic reconstructed images. The average spatial error was less than 4 mm, which is half the spatial resolution of the data acquisition system. The average SCR, CCR, and TFRR of the images reconstructed with the multistatic approach were 15.0, 9.4, and 10.0 dB, respectively. In comparison, monostatic images obtained using the datasets from the same experimental setups yielded average SCR, CCR, and TFRR values of 12.8, 4.9, and 5.9 dB. No artifacts, defined as responses generated by the reconstruction method of at least half the energy of the tumor signatures, were noted in the multistatic reconstructions. The average execution time of the images formed using the proposed approach was 4 s, which is one order of magnitude faster than the current state-of-the-art time-domain multistatic breast microwave radar reconstruction algorithms.

CONCLUSIONS

The images generated by the proposed method show that multistatic holography is capable of forming spatially accurate images in real-time with signal to clutter levels and contrast values higher than other published monostatic and multistatic cylindrical radar reconstruction approaches. In comparison to the monostatic holographic approach, the images generated by the proposed multistatic approach had SCR values that were at least 50% higher. The multistatic images had CCR and TFRR values at least 200% greater than those formed using a monostatic approach.

COST-RISK-BENEFIT ANALYSIS IN DIAGNOSTIC RADIOLOGY: A THEORETICAL AND ECONOMIC BASIS FOR RADIATION PROTECTION OF THE PATIENT

In 1973, International Commission on Radiological Protection Publication 22 recommended that the acceptability of radiation exposure levels for a given activity should be determined by a process of cost-benefit analysis. It was felt that this approach could be used to underpin both the principle of ALARA as well for justification purposes. The net benefit, B, of an operation involving irradiation was regarded as equal to the difference between its gross benefit, V, and the sum of three components; the basic production cost associated with the operation, P; the cost of achieving the selected level of protection, X; and the cost Y of the detriment involved in the operation: [Formula: see text] This article presents a theoretical cost-risk-benefit analysis that is applicable to the diagnostic accuracy (Levels 1 and 2) of the hierarchical efficacy model presented by National Council on Radiation Protection and Measurements in 1992. This enables the costs of an examination to be related to the sensitivity and specificity of an X-ray examination within a defined clinical problem setting and introduces both false-positive/false-negative diagnostic outcomes into the patient radiation protection framework.

Consequences of a false-positive mammography result: drug consumption before and after screening

Background Previous research showed women experiencing false-positive mammograms to have greater anxiety about breast cancer than women with normal mammograms. To elucidate psychological effects of false-positive mammograms, we studied impact on drug intake. Methods We calculated the ratio of drug use for women with false-positive versus women with normal mammograms, before and after the event, using population-based registers, 1997-2006. The ratio of the ratios (RRR) assessed the impact. Results Before the test, 40.3% of women from the false-positive group versus 36.2% from the normal group used anxiolytic and antidepressant drugs. There was no difference in use of beta blockers. Hormone therapy was used more frequently by the false-positive, 36.6% versus 28.7%. The proportion of women using anxiolytic and antidepressant drugs increased with 19% from the before to the after period in the false-positive group, and with 16% in the normal group, resulting in an RRR of 1.02 (95% CI 0.92-1.14). RRR was 1.03 for beta blockers, 0.97 for hormone therapy. Conclusion(s) Drugs used to mitigate mood disorders were used more frequently by women with false-positive than by women with normal mammograms already before the screening event, while the changes from before to after screening were similar for both groups. The results point to the importance of control for potential selection in studies of screening effects.

Body weight and sensitivity of screening mammography

AIM

Obese women tend to participate less in breast cancer screening than normal weight women. However, obese women have fattier breast than normal weight women, and screening mammography works better in fatty than in dense breasts. One might, therefore, hypothesise that obese women would actually benefit more from screening than other women.

METHODS

We combined data from the Danish Diet, Cancer and Health study and the organised population-based screening mammography programme in Copenhagen, Denmark. Women were categorised according to body mass index (BMI) (<20; 20 to <25; 25 to <30; 30 to <35, and 35+). We measured recall rate, sensitivity and specificity for subsequent screens with a 2-year follow-up period.

RESULTS

The study included 6787 women. The recall rate varied from 1.4% for women with BMI <20 to 1.9% for women with BMI 35+, test for trend p = 0.86. Sensitivity varied from 42% (95% confidence interval [CI] 20-64%) for women with BMI <20 to 100% (95% CI 69-100%) for women with BMI 35+, test for trend p = 0.015. Specificity was fairly constant across BMI levels, being on average 98.8%, test for trend p = 0.79.

CONCLUSION

This study showed that obese women were the ones with the highest sensitivity of screening mammography, while the specificity of screening remained stable across weight groups. Screening programmes should be organized to encourage these women to overcome obstacles for participation.

False positives in breast cancer screening with one-view breast tomosynthesis: An analysis of findings leading to recall, work-up and biopsy rates in the Malmö Breast Tomosynthesis Screening Trial

Objectives

To analyse false positives (FPs) in breast cancer screening with tomosynthesis (BT) vs. mammography (DM).

Methods

The Malmö Breast Tomosynthesis Screening Trial (MBTST) is a prospective population-based study comparing one-view BT to DM in screening. This study is based on the first half of the MBTST population (n = 7,500). Differences in FP recall rate, findings leading to recall, work-up and biopsy rate between cases recalled on BT alone, DM alone and BT+DM were analysed.

Results

The FP recall rate was 1.7 % for BT alone (n = 131), 0.9 % for DM alone (n = 69) and 1.1 % for BT + DM (n = 81). The FP recall rate for BT alone was halved after the initial phase of the trial, stabilising at 1.5 %. BT doubled the recall of stellate distortions compared to DM (n = 64 vs. n = 33). There were fewer fibroadenomas and cysts, and the biopsy rate was slightly lower for FP recalled on BT alone compared to DM alone (15.3 % vs. 27.6 %: p = 0.037 and 33.8 % vs. 36.2 %; p = 0.641, respectively).

Conclusions

FPs increased with BT screening mainly due to the recall of stellate distortions. The FP recall rate was still well within the European guidelines and showed evidence of a learning curve. Characterisation of rounded lesions was improved with BT.

Key Points

• Tomosynthesis screening gave a higher false-positive recall rate than mammography

• There was a decline in the false-positive recall rate for tomosynthesis

• The recall due to stellate distortions simulating malignancy was doubled with tomosynthesis

• Tomosynthesis found more radial and postoperative scar tissue than mammography

• Tomosynthesis is better at characterising rounded lesions

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

BACKGROUND

Women screened with digital mammography may receive false-positive and false-negative results and subsequent imaging and biopsies. How these outcomes vary by age, time since the last screening, and individual risk factors is unclear.

OBJECTIVE

To determine factors associated with false-positive and false-negative digital mammography results, additional imaging, and biopsies among a general population of women screened for breast cancer.

DESIGN

Analysis of registry data.

SETTING

Participating facilities at 5 U.S. Breast Cancer Surveillance Consortium breast imaging registries with linkages to pathology databases and tumor registries.

PATIENTS

405,191 women aged 40 to 89 years screened with digital mammography between 2003 and 2011. A total of 2963 were diagnosed with invasive cancer or ductal carcinoma in situ within 12 months of screening.

MEASUREMENTS

Rates of false-positive and false-negative results and recommendations for additional imaging and biopsies from a single screening round; comparisons by age, time since the last screening, and risk factors.

RESULTS

Rates of false-positive results (121.2 per 1000 women [95% CI, 105.6 to 138.7]) and recommendations for additional imaging (124.9 per 1000 women [CI, 109.3 to 142.3]) were highest among women aged 40 to 49 years and decreased with increasing age. Rates of false-negative results (1.0 to 1.5 per 1000 women) and recommendations for biopsy (15.6 to 17.5 per 1000 women) did not differ greatly by age. Results did not differ by time since the last screening. False-positive rates were higher for women with risk factors, particularly family history of breast cancer; previous benign breast biopsy result; high breast density; and, for younger women, low body mass index.

LIMITATIONS

Confounding by variation in patient-level characteristics and outcomes across registries and regions may have been present. Some factors, such as numbers of first- and second-degree relatives with breast cancer and diagnoses associated with previous benign biopsy results, were not examined.

CONCLUSION

False-positive mammography results and additional imaging are common, particularly for younger women and those with risk factors, whereas biopsies occur less often. Rates of false-negative results are low.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and National Cancer Institute.