Supplemental Breast Imaging Utilization After Breast Density Legislation in North Carolina

Screening mammography frequency following dense breast notification among a predominantly Hispanic/Latina screening cohort

PURPOSE

Nationally legislated dense breast notification (DBN) informs women of their breast density (BD) and the impact of BD on breast cancer risk and detection, but consequences for screening participation are unclear. We evaluated the association of DBN in New York State (NYS) with subsequent screening mammography in a largely Hispanic/Latina cohort.

METHODS

Women aged 40-60 were surveyed in their preferred language (33% English, 67% Spanish) during screening mammography from 2016 to 2018. We used clinical BD classification from mammography records from 2013 (NYS DBN enactment) through enrollment (baseline) to create a 6-category variable capturing prior and new DBN receipt (sent only after clinically dense mammograms). We used this variable to compare the number of subsequent mammograms (0, 1, ≥ 2) from 10 to 30 months after baseline using ordinal logistic regression.

RESULTS

In a sample of 728 women (78% foreign-born, 72% Hispanic, 46% high school education or less), first-time screeners and women who received DBN for the first time after prior non-dense mammograms had significantly fewer screening mammograms within 30 months of baseline (Odds Ratios range: 0.33 (95% Confidence Interval (CI) 0.12-0.85) to 0.38 (95% CI 0.17-0.82)) compared to women with prior mammography but no DBN. There were no differences in subsequent mammogram frequency between women with multiple DBN and those who never received DBN. Findings were consistent across age, language, health literacy, and education groups.

CONCLUSION

Women receiving their first DBN after previous non-dense mammograms have lower mammography participation within 2.5 years. DBN has limited influence on screening participation of first-time screeners and those with persistent dense mammograms.

The impact of mandatory mammographic breast density notification on supplemental screening practice in the United States: a systematic review

PURPOSE

Dense breast tissue is an independent risk factor for breast cancer and lowers the sensitivity of screening mammography. Supplemental screening with ultrasound or MRI improves breast cancer detection rate but has potential harms. Breast density notification (BDN) legislation has been introduced in the United States (US) and its impact on supplemental screening practice is unclear. This study systematically reviewed current evidence to explore the impact of BDN on supplemental screening practice in the US.

METHODS

Medline, PubMed, Embase, Cochrane and the Cinhal Library databases were searched (2009-August 2020). Studies were assessed for eligibility, data were extracted and summarised, and study quality was evaluated.

RESULTS

Evidence from the included studies (n = 14) predominantly showed that BDN legislation increased the overall utilisation of supplemental screening by 0.5-143%. This effect was amplified if the notification included a follow-up telephone call informing women about additional screening benefits, and if the state's law mandated insurance cover for supplemental screening. Likelihood of supplemental screening was also influenced by history of breast biopsy and family history of breast cancer, race, age, socioeconomic status, density category, and physician's specialty and region. Some studies reported increases in biopsy rate (up to 4%) and cancer detection rate (up to 11%) after implementation of BDN legislation.

CONCLUSION

BDN leads to increased use of supplemental screening. This has implications for women and the health system. These findings can help inform current and future screening programs, where breast density notification is currently implemented or being considered.

Radiologic Technologist and Radiologist Knowledge Gaps about Breast Density Revealed by an Online Continuing Education Course

OBJECTIVE

We sought to identify provider knowledge gaps and their predictors, as revealed by a breast density continuing education course marketed to the radiology community.

METHODS

The course, continually available online during the study period of November 2, 2016 and December 31, 2018, includes demographics collection; a monograph on breast density, breast cancer risk, and screening; and a post-test. Four post-test questions were modified during the study period, resulting in different sample sizes pre- and postmodification. Multiple logistic regression was used to identify predictors of knowledge gaps (defined as > 25% of responses incorrect).

RESULTS

Of 1649 analyzable registrants, 1363 (82.7%) were radiologic technologists, 226 (13.7%) were physicians, and 60 (3.6%) were other nonphysicians; over 90% of physicians and over 90% of technologists/nonphysicians specialized in radiology. Sixteen of 49 physicians (32.7%) and 80/233 (34.3%) technologists/nonphysicians mistakenly thought the Gail model should be used to determine "high-risk" status for recommending MRI or genetic testing. Ninety-nine of 226 (43.8%) physicians and 682/1423 (47.9%) technologists/nonphysicians misunderstood the inverse relationship between increasing age and lifetime breast cancer risk. Fifty-two of 166 (31.3%) physicians and 549/1151 (47.7%) technologists/nonphysicians were unaware that MRI should be recommended for women with a family history of BRCA1/BRCA2 mutations. Tomosynthesis effectiveness was overestimated, with 18/60 (30.0%) physicians and 95/272 (34.9%) technologists/nonphysicians believing sensitivity nearly equaled MRI. Knowledge gaps were more common in technologists/nonphysicians.

CONCLUSIONS

Important knowledge gaps about breast density, breast cancer risk assessment, and screening exist among radiologic technologists and radiologists. Continued education efforts may improve appropriate breast cancer screening recommendations.