Decreased accuracy in interpretation of community-based screening mammography for women with multiple clinical risk factors

"I'm Just Guessing These Answers!" An Evaluation of the (In)Accuracy of Patient-Reported Medical History Collected as Part of a Breast Imaging Program

INTRODUCTION

Hundreds of thousands of Ontario women receive breast screening imaging each year. The patient's medical history is a vital tool used to personalize breast screening approaches. This study evaluated the accuracy of self-reported medical and imaging history in patients about to receive breast imaging procedures in a large urban Canadian hospital. The patient experience with using a blank screening form vs. a novel prefilled screening form was also evaluated.

METHODS AND MATERIALS

The study was conducted in two phases. Phase 1 compared patient-reported information (via the blank screening form) to information previously captured in the Radiology Information and Picture Archiving Communication Systems to assess data accuracy. In phase 2, study questionnaires were used to collect data on the patients' experience with the screening form in two cohorts (between the blank and a novel prefilled screening form).

RESULTS

Data accuracy: for mammography (n = 60), 40% of the patients could accurately recall when and where their last mammogram was performed. For breast ultrasound (n = 43) and breast magnetic resonance imaging (n = 20), significantly fewer patients could accurately recall the date their last test was performed (14% and 10%, respectively). Of those who had previous breast surgery (n = 18), 100% were able to recall whether the surgery resulted in a benign or malignant diagnosis, and 61% were able to accurately recall the year they had the breast surgery.

PATIENT EXPERIENCE

Of the returned questionnaires, 65 provided feedback on the blank screening form while 55 provided feedback on the prefilled form. Ninety percent preferred to fill out the new prefilled screening form. The themes acknowledged a general improvement in the screening form, a decrease in frustration associated with having to recall their medical history, and the patients felt that the institution better understood their medical history.

CONCLUSIONS

The findings of this research indicate that asking patients to complete a blank medical screening form is a highly inaccurate method of gathering that important information. When that information was prefilled for the patient to review and update, patient frustration and stress were decreased, while satisfaction and confidence in the organization were increased.

Association between Screening Mammography Recall Rate and Interval Cancers in the UK Breast Cancer Service Screening Program: A Cohort Study

Purpose To determine whether low levels of recall lead to increased interval cancers and the magnitude of this effect. Materials and Methods The authors retrospectively analyzed prospectively collected data from the UK National Health Service Breast Screening Programme during a 36-month period (April 1, 2005 to March 31, 2008), with 3-year follow-up in women aged 50-70 years. Data on recall, cancers detected at screening, and interval cancers were available for each of the 84 breast screening units and for each year (n = 252). The association between interval cancers and recalls was modeled by using Poisson regression on aggregated data and according to age (5-year intervals) and screening type (prevalent vs incident). Results The authors analyzed 5 126 689 screening episodes, demonstrating an average recall to assessment rate (RAR) of 4.56% (range, 1.64%-8.42%; standard deviation, 1.15%), cancer detection rate of 8.1 per 1000 women screened, and interval cancer rate (ICR) of 3.1 per 1000 women screened. Overall, a significant negative association was found between RAR and ICR (Poisson regression coefficient: -0.039 [95% confidence interval: -0.062, -0.017]; P = .001), with approximately one fewer interval cancer for every additional 80-84 recalls. Subgroup analysis revealed similar negative correlations in women aged 50-54 years (P = .002), 60-64 years (P = .01), and 65-69 years (P = .008) as well as in incident screens (P = .001) and prevalent screens (P = .04). No significant relationship was found in women aged 55-59 years (P = .46). Conclusion There was a statistically significant negative correlation between RAR and ICR, which suggests the merit of a minimum threshold for RAR. © RSNA, 2018 Online supplemental material is available for this article.

Molecular Breast Imaging for Screening in Dense Breasts: State of the Art and Future Directions

OBJECTIVE

The purposes of this review are to discuss the motivation for supplemental screening, to address molecular breast imaging (MBI) radiation dose concerns, and to provide an updated guide to current MBI technology, clinical protocols, and screening performance. Future directions of MBI are also discussed.

CONCLUSION

MBI offers detection of mammographically occult cancers in women with dense breasts. Although MBI has been under investigation for nearly 15 years, it has yet to gain widespread adoption in breast screening.

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.

Patient and Radiologist Characteristics Associated With Accuracy of Two Types of Diagnostic Mammograms

OBJECTIVE

Earlier studies of diagnostic mammography found wide unexplained variability in accuracy among radiologists. We assessed patient and radiologist characteristics associated with the interpretive performance of two types of diagnostic mammography.

MATERIALS AND METHODS

Radiologists interpreting mammograms in seven regions of the United States were invited to participate in a survey that collected information on their demographics, practice setting, breast imaging experience, and self-reported interpretive volume. Survey data from 244 radiologists were linked to data on 274,401 diagnostic mammograms performed for additional evaluation of a recent abnormal screening mammogram or to evaluate a breast problem, between 1998 and 2008. These data were also linked to patients' risk factors and follow-up data on breast cancer. We measured interpretive performance by false-positive rate, sensitivity, and AUC. Using logistic regression, we evaluated patient and radiologist characteristics associated with false-positive rate and sensitivity for each diagnostic mammogram type.

RESULTS

Mammograms performed for additional evaluation of a recent mammogram had an overall false-positive rate of 11.9%, sensitivity of 90.2%, and AUC of 0.894; examinations done to evaluate a breast problem had an overall false-positive rate of 7.6%, sensitivity of 83.9%, and AUC of 0.871. Multiple patient characteristics were associated with measures of interpretive performance, and radiologist academic affiliation was associated with higher sensitivity for both indications for diagnostic mammograms.

CONCLUSION

These results indicate the potential for improved radiologist training, using evaluation of their own performance relative to best practices, and for improved clinical outcomes with health care system changes to maximize access to diagnostic mammography interpretation in academic settings.

Criteria for identifying radiologists with acceptable screening mammography interpretive performance on basis of multiple performance measures

OBJECTIVE

Using a combination of performance measures, we updated previously proposed criteria for identifying physicians whose performance interpreting screening mammography may indicate suboptimal interpretation skills.

MATERIALS AND METHODS

In this study, six expert breast imagers used a method based on the Angoff approach to update criteria for acceptable mammography performance on the basis of two sets of combined performance measures: set 1, sensitivity and specificity for facilities with complete capture of false-negative cancers; and set 2, cancer detection rate (CDR), recall rate, and positive predictive value of a recall (PPV1) for facilities that cannot capture false-negative cancers but have reliable cancer follow-up information for positive mammography results. Decisions were informed by normative data from the Breast Cancer Surveillance Consortium (BCSC).

RESULTS

Updated combined ranges for acceptable sensitivity and specificity of screening mammography are sensitivity≥80% and specificity≥85% or sensitivity 75-79% and specificity 88-97%. Updated ranges for CDR, recall rate, and PPV1 are: CDR≥6 per 1000, recall rate 3-20%, and any PPV1; CDR 4-6 per 1000, recall rate 3-15%, and PPV1≥3%; or CDR 2.5-4.0 per 1000, recall rate 5-12%, and PPV1 3-8%. Using the original criteria, 51% of BCSC radiologists had acceptable sensitivity and specificity; 40% had acceptable CDR, recall rate, and PPV1. Using the combined criteria, 69% had acceptable sensitivity and specificity and 62% had acceptable CDR, recall rate, and PPV1.

CONCLUSION

The combined criteria improve previous criteria by considering the interrelationships of multiple performance measures and broaden the acceptable performance ranges compared with previous criteria based on individual measures.

The influence of mammographic technologists on radiologists' ability to interpret screening mammograms in community practice

RATIONALE AND OBJECTIVES

To determine whether the mammographic technologist has an effect on the radiologists' interpretative performance of screening mammography in community practice.

MATERIALS AND METHODS

In this institutional review board-approved retrospective cohort study, we included Carolina Mammography Registry data from 372 radiologists and 356 mammographic technologists from 1994 to 2009 who performed 1,003,276 screening mammograms. Measures of interpretative performance (recall rate, sensitivity, specificity, positive predictive value [PPV1], and cancer detection rate [CDR]) were ascertained prospectively with cancer outcomes collected from the state cancer registry and pathology reports. To determine if the mammographic technologist influenced the radiologists' performance, we used mixed effects logistic regression models, including a radiologist-specific random effect and taking into account the clustering of examinations across women, separately for screen-film mammography (SFM) and full-field digital mammography (FFDM).

RESULTS

Of the 356 mammographic technologists included, 343 performed 889,347 SFM examinations, 51 performed 113,929 FFDM examinations, and 38 performed both SFM and FFDM examinations. A total of 4328 cancers were reported for SFM and 564 cancers for FFDM. The technologists had a statistically significant effect on the radiologists' recall rate, sensitivity, specificity, and CDR for both SFM and FFDM (P values <.01). For PPV1, variability by technologist was observed for SFM (P value <.0001) but not for FFDM (P value = .088).

CONCLUSIONS

The interpretative performance of radiologists in screening mammography varies substantially by the technologist performing the examination. Additional studies should aim to identify technologist characteristics that may explain this variation.

What effect does mammographic breast density have on lesion detection in digital mammography?

Effective detection of breast cancer using mammography is an important public health issue worldwide. Breasts that contain higher levels of fibroglandular compared with fatty tissue increase breast radio-opacity making it more difficult to differentiate between normal and abnormal findings. The higher prevalence of breast cancer amongst women with denser breasts demands the origination of effective solutions to manage this common radiographic appearance. This brief review considers the impact of higher levels of density on cancer detection and the importance of digital technology in possibly reducing the negative effects of increased density.

Use of clinical history affects accuracy of interpretive performance of screening mammography

OBJECTIVE

To examine how use of clinical history affects radiologist's interpretation of screening mammography.

STUDY DESIGN AND SETTING

Using a self-administered survey and actual interpretive performance, we examined associations between use of clinical history and sensitivity, false-positive rate, recall rate, and positive predictive value, after adjusting for relevant covariates using conditional logistic regression.

RESULTS

Of the 216 radiologists surveyed (63.4%), most radiologists reported usually or always using clinical history when interpreting screening mammography. Compared with radiologists who rarely use clinical history, radiologists who usually or always use it had a higher false-positive rate with younger women (10.7 vs. 9.7), denser breast tissue (10.1 for heterogeneously dense to 10.9 for extremely dense vs. 8.9 for fatty tissue), or longer screening intervals (> prior 5 years) (12.5 vs. 10.5). Effect of current hormone therapy (HT) use on false-positive rate was weaker among radiologists who use clinical history compared with those who did not (P=0.01), resulting in fewer false-positive examinations and a nonsignificant lower sensitivity (79.2 vs. 85.2) among HT users.

CONCLUSION

Interpretive performance appears to be influenced by patient age, breast density, screening interval, and HT use. This influence does not always result in improved interpretive performance.

Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study

BACKGROUND

False-positive mammography results are common. Biennial screening may decrease the cumulative probability of false-positive results across many years of repeated screening but could also delay cancer diagnosis.

OBJECTIVE

To compare the cumulative probability of false-positive results and the stage distribution of incident breast cancer after 10 years of annual or biennial screening mammography.

DESIGN

Prospective cohort study.

SETTING

7 mammography registries in the National Cancer Institute-funded Breast Cancer Surveillance Consortium.

PARTICIPANTS

169,456 women who underwent first screening mammography at age 40 to 59 years between 1994 and 2006 and 4492 women with incident invasive breast cancer diagnosed between 1996 and 2006.

MEASUREMENTS

False-positive recalls and biopsy recommendations stage distribution of incident breast cancer.

RESULTS

False-positive recall probability was 16.3% at first and 9.6% at subsequent mammography. Probability of false-positive biopsy recommendation was 2.5% at first and 1.0% at subsequent examinations. Availability of comparison mammograms halved the odds of a false-positive recall (adjusted odds ratio, 0.50 [95% CI, 0.45 to 0.56]). When screening began at age 40 years, the cumulative probability of a woman receiving at least 1 false-positive recall after 10 years was 61.3% (CI, 59.4% to 63.1%) with annual and 41.6% (CI, 40.6% to 42.5%) with biennial screening. Cumulative probability of false-positive biopsy recommendation was 7.0% (CI, 6.1% to 7.8%) with annual and 4.8% (CI, 4.4% to 5.2%) with biennial screening. Estimates were similar when screening began at age 50 years. A non-statistically significant increase in the proportion of late-stage cancers was observed with biennial compared with annual screening (absolute increases, 3.3 percentage points [CI, -1.1 to 7.8 percentage points] for women age 40 to 49 years and 2.3 percentage points [CI, -1.0 to 5.7 percentage points] for women age 50 to 59 years) among women with incident breast cancer.

LIMITATIONS

Few women underwent screening over the entire 10-year period. Radiologist characteristics influence recall rates and were unavailable. Most mammograms were film rather than digital. Incident cancer was analyzed in a small sample of women who developed cancer.

CONCLUSION

After 10 years of annual screening, more than half of women will receive at least 1 false-positive recall, and 7% to 9% will receive a false-positive biopsy recommendation. Biennial screening appears to reduce the cumulative probability of false-positive results after 10 years but may be associated with a small absolute increase in the probability of late-stage cancer diagnosis.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study

BACKGROUND

False-positive mammography results are common. Biennial screening may decrease the cumulative probability of false-positive results across many years of repeated screening but could also delay cancer diagnosis.

OBJECTIVE

To compare the cumulative probability of false-positive results and the stage distribution of incident breast cancer after 10 years of annual or biennial screening mammography.

DESIGN

Prospective cohort study.

SETTING

7 mammography registries in the National Cancer Institute-funded Breast Cancer Surveillance Consortium.

PARTICIPANTS

169,456 women who underwent first screening mammography at age 40 to 59 years between 1994 and 2006 and 4492 women with incident invasive breast cancer diagnosed between 1996 and 2006.

MEASUREMENTS

False-positive recalls and biopsy recommendations stage distribution of incident breast cancer.

RESULTS

False-positive recall probability was 16.3% at first and 9.6% at subsequent mammography. Probability of false-positive biopsy recommendation was 2.5% at first and 1.0% at subsequent examinations. Availability of comparison mammograms halved the odds of a false-positive recall (adjusted odds ratio, 0.50 [95% CI, 0.45 to 0.56]). When screening began at age 40 years, the cumulative probability of a woman receiving at least 1 false-positive recall after 10 years was 61.3% (CI, 59.4% to 63.1%) with annual and 41.6% (CI, 40.6% to 42.5%) with biennial screening. Cumulative probability of false-positive biopsy recommendation was 7.0% (CI, 6.1% to 7.8%) with annual and 4.8% (CI, 4.4% to 5.2%) with biennial screening. Estimates were similar when screening began at age 50 years. A non-statistically significant increase in the proportion of late-stage cancers was observed with biennial compared with annual screening (absolute increases, 3.3 percentage points [CI, -1.1 to 7.8 percentage points] for women age 40 to 49 years and 2.3 percentage points [CI, -1.0 to 5.7 percentage points] for women age 50 to 59 years) among women with incident breast cancer.

LIMITATIONS

Few women underwent screening over the entire 10-year period. Radiologist characteristics influence recall rates and were unavailable. Most mammograms were film rather than digital. Incident cancer was analyzed in a small sample of women who developed cancer.

CONCLUSION

After 10 years of annual screening, more than half of women will receive at least 1 false-positive recall, and 7% to 9% will receive a false-positive biopsy recommendation. Biennial screening appears to reduce the cumulative probability of false-positive results after 10 years but may be associated with a small absolute increase in the probability of late-stage cancer diagnosis.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Effect of previous benign breast biopsy on the interpretive performance of subsequent screening mammography

BACKGROUND

Most breast biopsies will be negative for cancer. Benign breast biopsy can cause changes in the breast tissue, but whether such changes affect the interpretive performance of future screening mammography is not known.

METHODS

We prospectively evaluated whether self-reported benign breast biopsy was associated with reduced subsequent screening mammography performance using examination data from the mammography registries of the Breast Cancer Surveillance Consortium from January 2, 1996, through December 31, 2005. A positive interpretation was defined as a recommendation for any additional evaluation. Cancer was defined as any invasive breast cancer or ductal carcinoma in situ diagnosed within 1 year of mammography screening. Measures of mammography performance (sensitivity, specificity, and positive predictive value 1 [PPV1]) were compared both at woman level and breast level in the presence and absence of self-reported benign biopsy history. Referral to biopsy was considered a positive interpretation to calculate positive predictive value 2 (PPV2). Multivariable analysis of a correct interpretation on each performance measure was conducted after adjusting for registry, year of examination, patient characteristics, months since last mammogram, and availability of comparison film. Accuracy of the mammogram interpretation was measured using area under the receiver operating characteristic curve (AUC). All statistical tests were two-sided.

RESULTS

A total of 2,007,381 screening mammograms were identified among 799,613 women, of which 14.6% mammograms were associated with self-reported previous breast biopsy. Multivariable adjusted models for mammography performance showed reduced specificity (odds ratio [OR] = 0.74, 95% confidence interval [CI] = 0.73 to 0.75, P < .001), PPV2 (OR = 0.85, 95% CI = 0.79 to 0.92, P < .001), and AUC (AUC 0.892 vs 0.925, P < .001) among women with self-reported benign biopsy. There was no difference in sensitivity or PPV1 in the same adjusted models, although unadjusted differences in both were found. Specificity was lowest among women with documented fine needle aspiration-the least invasive biopsy technique (OR = 0.58, 95% CI = 0.55 to 0.61, P < .001). Repeating the analysis among women with documented biopsy history, unilateral biopsy history, or restricted to invasive cancers did not change the results.

CONCLUSIONS

Self-reported benign breast biopsy history was associated with statistically significantly reduced mammography performance. The difference in performance was likely because of tissue characteristics rather than the biopsy itself.