Evolution of breast cancer screening in the Medicare population: clinical and economic implications

Detailed Image Data Quality and Cleaning Practices for Artificial Intelligence Tools for Breast Cancer

Standardizing image-data preparation practices to improve accuracy/consistency of AI diagnostic tools.

Estimating Breast Cancer Overdiagnosis After Screening Mammography Among Older Women in the United States

BACKGROUND

Overdiagnosis is increasingly recognized as a harm of breast cancer screening, particularly for older women.

OBJECTIVE

To estimate overdiagnosis associated with breast cancer screening among older women by age.

DESIGN

Retrospective cohort study comparing the cumulative incidence of breast cancer among older women who continued screening in the next interval with those who did not. Analyses used competing risk models, stratified by age.

SETTING

Fee-for-service Medicare claims, linked to the SEER (Surveillance, Epidemiology, and End Results) program.

PATIENTS

Women 70 years and older who had been recently screened.

MEASUREMENTS

Breast cancer diagnoses and breast cancer death for up to 15 years of follow-up.

RESULTS

This study included 54 635 women. Among women aged 70 to 74 years, the adjusted cumulative incidence of breast cancer was 6.1 cases (95% CI, 5.7 to 6.4) per 100 screened women versus 4.2 cases (CI, 3.5 to 5.0) per 100 unscreened women. An estimated 31% of breast cancer among screened women were potentially overdiagnosed. For women aged 75 to 84 years, cumulative incidence was 4.9 (CI, 4.6 to 5.2) per 100 screened women versus 2.6 (CI, 2.2 to 3.0) per 100 unscreened women, with 47% of cases potentially overdiagnosed. For women aged 85 and older, the cumulative incidence was 2.8 (CI, 2.3 to 3.4) among screened women versus 1.3 (CI, 0.9 to 1.9) among those not, with up to 54% overdiagnosis. We did not see statistically significant reductions in breast cancer-specific death associated with screening.

LIMITATIONS

This study was designed to estimate overdiagnosis, limiting our ability to draw conclusions on all benefits and harms of screening. Unmeasured differences in risk for breast cancer and differential competing mortality between screened and unscreened women may confound results. Results were sensitive to model specifications and definition of a screening mammogram.

CONCLUSION

Continued breast cancer screening was associated with greater incidence of breast cancer, suggesting overdiagnosis may be common among older women who are diagnosed with breast cancer after screening. Whether harms of overdiagnosis are balanced by benefits and for whom remains an important question.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Tendency to Breast Cancer Screening Among Rural Women in Southern Iran: A Structural Equation Modeling (SEM) Analysis of Theory of Planned Behavior

BACKGROUND

Early detection of breast cancer is a crucial factor in surviving the disease. This study aimed to investigate the mammography screening based on the theory of planned behavior (TPB) among rural women in Fasa and Shiraz cities, Iran.

METHODS

This study is a cross-sectional study performed on 800 female clients referring to rural health centers in Fasa and Shiraz cities in southern Iran in early 2021. The authors decided to send and distribute the electronic questionnaire form through the WhatsApp application in collaboration with the health staff of rural health centers for the people covered by these centers. Data gathering tools were a questionnaire on demographic characteristics, a questionnaire based on constructs of TPB, and behavior of mammography screening. Using the structural equation model (SEM), the TPB constructs and demographic variables were entered into the model. Data analysis was executed employing SPSS software version 26 and Amos version 24 (IBM Co., Ann Arbor, MI, USA). Analyzing the data was carried out using the 1-way analysis of variance (ANOVA), logistic regression, and structural equation analysis. During data analysis, various model indicators such as the goodness of fit, including comparative fit index (CFI), goodness-of-fit index (GFI), root mean square error of approximation (RMSEA), and chi-square index/df were evaluated. The significance level in all tests was considered 0.05.

RESULTS

The knowledge, attitude, and perceived behavioral control were the predictors of intention and behavior of mammography screening among the women. Among demographic variables, age, literacy, being menopausal, cancer in family, city, and ethnicity contribute more to the variance variation in TPB constructs. In this study, 7.2% of Persians, 8% of Qashqai Turks, and 4.5% of Arabs are contemplating going to mammography screening. In total, 6.8% (54 people) of all individuals intended to go mammography screening, and 5.4% (43 people) had a history of mammography screening. Goodness-of-fit indices (χ2 = 18.45, df = 10, n = 800, χ2/df = 1.845, RMSEA = 0.032, GFI = 0.90, non-normed fit index (NNFI) = 0.91) of conceptual model of this study indicate the suitability of the model.

CONCLUSIONS

The results of the study indicated that the constructs of the TPB can predict mammography screening behaviors in rural women. It has also demonstrated that mammographic behavior can be improved in rural women using education based on the TPB model, emphasizing critical psychological factors of creating or changing behavior.

The concordance in lesion detection and characteristics between the Anatomical Intelligence and conventional breast ultrasound Scan method

Background

The aim of this study was to investigate the concordance in lesion detection, between conventional Handhold Ultrasound (HHUS) and The Anatomical Intelligence for Breast ultrasound scan method.

Result

The AI-breast showed the absolute agreement between the resident and an experienced breast radiologist. The ICC for the scan time, number, clockface location, distance to the nipple, largest diameter and mean diameter of the lesion obtained by a resident and an experienced breast radiologist were 0.7642, 0.7692, 0.8651, 0.8436, 0.7502, 0.8885, respectively. The ICC of the both practitioners of AI-breast were 0.7971, 0.7843, 0.9283, 0.8748, 0.7248, 0.8163, respectively. The k value of Anatomical Intelligence breast between experienced breast radiologist and resident in these image characteristics of boundary, morphology, aspect ratio, internal echo, and BI-RADS assessment were 0.7424, 0.7217, 0.6741, 0.6419, 0.6241, respectively. The k value of the two readers of AI-breast were 0.6531, 0.6762, 0.6439, 0.6137, 0.5981, respectively.

Conclusion

The anatomical intelligent breast US scanning method has excellent reproducibility in recording the lesion location and the distance from the nipple, which may be utilized in the lesions surveillance in the future.

Determinants of mammography screening in Tehranian women in 2018 based on the health belief model: A cross-sectional study

BACKGROUND

Breast cancer is the most common type of cancer among women. Mammography is the most sensitive and important method for screening and early diagnosis of breast cancer. Considering the importance of using mammography in breast cancer screening, this study was performed to evaluate mammographic determinants.

MATERIALS AND METHODS

In the cross-sectional study, we surveyed 985 women over 40 years in Tehran concerning demographic characteristics: age, socioeconomic status, a problem in the breast, alcohol use, drug use, and health belief model. Logistic regression was used to identify determinant factors associated with mammography performance.

RESULTS

The results of this study showed that 42.1% (95% confidence interval [CI]: 38, 45) participant performed mammography at least once during their lifetime. Age (odds ratio [OR] = 4.252; 95% CI = 2.041-8.857); housing situation (OR = 1.706; 95% CI = 1.178-2.469); having breast problems (OR = 5.224; 95% CI = 3.501-7.795); socioeconomic status (OR = 1.855; 95% CI = 1.035-3.325); family income level (OR = 1.998; 95% CI = 1.028-3.884); alcohol consumption (OR = 2.676; 95% CI = 1.344-5.328); smoking (OR = 2.824; 95% CI = 1.418-5.623); self-efficacy (OR = 1.935; 95% CI = 1.242-3.015); perceived barriers (OR = 2.017; 95% CI = 1.348-3.019); self-care (OR = 4.901; 95% CI = 3.152-7.620); perceived susceptibility (OR = 1.971; 95% CI = 1.271-3.057) and perceived severity (OR = 1.830; 95% CI = 1.170-2.860) were mammography behaviors determinants.

CONCLUSION

The findings indicated that the rate of mammography screening among Tehranian women is low and highlights the need for developing a comprehensive national breast cancer control program, which should be considered as the priority for health-care providers. Furthermore, the identification of these factors can help to design an appropriate educational intervention that focuses on the benefits of mammography screening.

The association of chronic diseases and mammography among Medicare beneficiaries living in Appalachia

OBJECTIVE

This study assessed the relationship between presence and number of chronic disease and reception of mammogram in women 65 years and older, and how this relationship is influenced by primary care provider visits.

METHODS

A total of 3306 women diagnosed with breast cancer from 2006 to 2008 from cancer registries in four Appalachian states were analyzed.

RESULTS

Having a mammogram within the past 2 years was associated with having at least one chronic disease. The presence of a chronic disease was associated with an increased likelihood of breast cancer screening adherence but was not a strong predictor when demographic variables were added.

CONCLUSION

This study supports the findings that women with more primary care provider visits were more likely to adhere to breast cancer screening guidelines but having several chronic diseases presents a barrier to achieving guideline-concordant mammography screening, highlighting the importance of preventive screening for patients managing chronic diseases.

Computer-Aided Detection for Breast Cancer Screening in Clinical Settings: Scoping Review

BACKGROUND

With the growth of machine learning applications, the practice of medicine is evolving. Computer-aided detection (CAD) is a software technology that has become widespread in radiology practices, particularly in breast cancer screening for improving detection rates at earlier stages. Many studies have investigated the diagnostic accuracy of CAD, but its implementation in clinical settings has been largely overlooked.

OBJECTIVE

The aim of this scoping review was to summarize recent literature on the adoption and implementation of CAD during breast cancer screening by radiologists and to describe barriers and facilitators for CAD use.

METHODS

The MEDLINE database was searched for English, peer-reviewed articles that described CAD implementation, including barriers or facilitators, in breast cancer screening and were published between January 2010 and March 2018. Articles describing the diagnostic accuracy of CAD for breast cancer detection were excluded. The search returned 526 citations, which were reviewed in duplicate through abstract and full-text screening. Reference lists and cited references in the included studies were reviewed.

RESULTS

A total of nine articles met the inclusion criteria. The included articles showed that there is a tradeoff between the facilitators and barriers for CAD use. Facilitators for CAD use were improved breast cancer detection rates, increased profitability of breast imaging, and time saved by replacing double reading. Identified barriers were less favorable perceptions of CAD compared to double reading by radiologists, an increase in recall rates of patients for further testing, increased costs, and unclear effect on patient outcomes.

CONCLUSIONS

There is a gap in the literature between CAD's well-established diagnostic accuracy and its implementation and use by radiologists. Generally, the perceptions of radiologists have not been considered and details of implementation approaches for adoption of CAD have not been reported. The cost-effectiveness of CAD has not been well established for breast cancer screening in various populations. Further research is needed on how to best facilitate CAD in radiology practices in order to optimize patient outcomes, and the views of radiologists need to be better considered when advancing CAD use.

Medicare Cancer Screening in the Context of Clinical Guidelines: 2000 to 2012

OBJECTIVES

Cancer screening is a ubiquitous and controversial public health issue, particularly in the elderly population. Despite extensive evidence-based guidelines for screening, it is unclear how cancer screening has changed in the Medicare population over time. We characterize trends in cancer screening for the most common cancer types in the Medicare fee-for-service (FFS) program in the context of conflicting guidelines from 2000 to 2012.

MATERIALS AND METHODS

We performed a descriptive analysis of retrospective claims data from the Medicare FFS program based on billing codes. Our data include all claims for Medicare part B beneficiaries who received breast, colorectal (CRC), or prostate cancer screening from 2000 to 2012 based on billing codes. We utilize a Monte Carlo permutation method to detect changes in screening trends.

RESULTS

In total, 231,416,732 screening tests were analyzed from 2000 to 2012, representing an average of 436.8 tests per 1000 beneficiaries per year. Mammography rates declined 7.4%, with digital mammography extensively replacing film. CRC cancer screening rates declined overall. As a percentage of all CRC screening tests, colonoscopy grew from 32% to 71%. Prostate screening rates increased 16% from 2000 to 2007, and then declined to 7% less than its 2000 rate by 2012.

DISCUSSION

Both the aggressiveness of screening guidelines and screening rates for the Medicare FFS population peaked and then declined from 2000 to 2012. However, guideline publications did not consistently precede utilization trend shifts. Technology adoption, practical and financial concerns, and patient preferences may have also contributed to the observed trends. Further research should be performed on the impact of multiple, conflicting guidelines in cancer screening.

Plasma phospholipase A2 activity may serve as a novel diagnostic biomarker for the diagnosis of breast cancer

Previous studies have indicated that phospholipase A2 (PLA2) may be associated with tumorigenesis in human tissues. The present study aimed to investigate the association between plasma PLA2 activity and the breast cancer (BC) status of patients. Increased plasma PLA2 activity was detected in patients with breast cancer when compared with healthy controls. Plasma samples were obtained from patients with BC (n=169), patients with benign disease (BD; n=80) and healthy controls (n=81). PLA2 activity was assessed using a quantitative fluorescent assay with selective inhibitors. It was demonstrated that increased PLA2 and secretory PLA2 (sPLA2) activity was associated with tumor stage, particularly in patients with late-stage disease. Additionally, smoking, alcohol consumption, body mass index (BMI) and age of patients did not have a significant effect on PLA2 activity. Analysis of receiver operating characteristic curves revealed that plasma PLA2 and sPLA2 activities were increased in BC patients compared with healthy controls. It was concluded that plasma PLA2 activity may serve as a biomarker for patients with BC.

Abbreviated screening protocol for breast MRI: a feasibility study

RATIONALE AND OBJECTIVES

To compare the performance of two shortened breast magnetic resonance imaging (MRI) protocols to a standard MRI protocol for breast cancer screening.

MATERIALS AND METHODS

In this Health Insurance Portability and Accountability Act compliant, institutional review board-approved pilot study, three fellowship-trained breast imagers evaluated 48 breast MRIs (24 normal, 12 benign, and 12 malignant) selected from a high-risk screening population. MRIs were presented in three viewing protocols, and a final Breast Imaging-Reporting and Data System assessment was recorded for each case. The first shortened protocol (abbreviated 1) included only fat-saturated precontrast T2-weighted, precontrast T1-weighted, and first pass T1-weighted postcontrast sequences. The second shortened protocol (abbreviated 2) included the abbreviated 1 protocol plus the second pass T1-weighted postcontrast sequence. The third protocol (full), reviewed after a 1-month waiting period, included a nonfat-saturated T1-weighted sequence, fat-saturated T2-weighted, precontrast T1-weighted, and three or four dynamic postcontrast sequences. Interpretation times were recorded for the abbreviated 1 and full protocols. Sensitivity and specificity were compared via a chi-squared analysis. This pilot study was designed to detect a 10% difference in sensitivity with a power of 0.8.

RESULTS

There was no significant difference in sensitivity between the abbreviated 1 (86%; P = .22) or abbreviated 2 (89%; P = .38) protocols and the full protocol (95%). There was no significant difference in specificity between the abbreviated 1 (52%; P = 1) or abbreviated 2 (45%; P = .34) protocols and the full protocol (52%). The abbreviated 1 and full protocol interpretation times were similar (2.98 vs. 3.56 minutes).

CONCLUSIONS

In this pilot study, reader performance comparing two shortened breast MRI protocols to a standard protocol in a screening cohort were similar, suggesting that a shortened breast MRI protocol may be clinically useful, warranting further investigation.

Diagnostic workup and costs of a single supplemental molecular breast imaging screen of mammographically dense breasts

OBJECTIVE

The purpose of this study was to examine additional diagnostic workup and costs generated by addition of a single molecular breast imaging (MBI) examination to screening mammography for women with dense breasts.

SUBJECTS AND METHODS

Women with mammographically dense breasts presenting for screening mammography underwent adjunct MBI performed with 300 MBq (99m)Tc-sestamibi and a direct-conversion cadmium-zinc-telluride dual-head gamma camera. All subsequent imaging tests and biopsies were tracked for a minimum of 1 year. The positive predictive value of biopsies performed (PPV3), benign biopsy rate, cost per patient screened, and cost per cancer detected were determined.

RESULTS

A total of 1651 women enrolled in the study. Among the 1585 participants with complete reference standard, screening mammography alone prompted diagnostic workup of 175 (11.0%) patients and biopsy of 20 (1.3%) and yielded five malignancies (PPV3, 25%). Results of combined screening mammography plus MBI prompted diagnostic workup of 279 patients (17.6%) and biopsy of 67 (4.2%) and yielded 19 malignancies (PPV3, 28.4%). The benign biopsy rates were 0.9% (15 of 1585) for screening mammography alone and 3.0% (48 of 1585) for the combination (p < 0.001). The addition of MBI increased the cost per patient screened from $176 for mammography alone to $571 for the combination. However, cost per cancer detected was lower for the combination ($47,597) than for mammography alone ($55,851).

CONCLUSION

The addition of MBI to screening mammography of women with dense breasts increased the overall costs and benign biopsy rate but also increased the cancer detection rate, which resulted in a lower cost per cancer detected than with screening mammography alone.

Molecular breast imaging: an emerging modality for breast cancer screening

Screening mammography is recognized as an imperfect imaging tool that performs poorly in women with dense breast tissue - a limitation which has driven demand for supplemental screening techniques. One potential supplemental technique is molecular breast imaging (MBI). Significant improvements in gamma camera technology allow MBI to be performed at low radiation doses, comparable with those of tomosynthesis and mammography. A recent screening trial in women with dense breast tissue yielded a cancer detection rate of 3.2 per 1000 for mammography alone and 12.0 per 1000 for the combination of mammography and MBI. MBI also demonstrated a lower recall rate than that of mammography. MBI is a promising supplemental screening technique in women with dense breast tissue.