A private breast imaging practice: medical audit of 25,788 screening and 1,077 diagnostic examinations

Using the Medical Audit to Improve Practice Performance

Feedback to physicians on their clinical performance is critical to continuous learning and maintenance of skills as well as maintaining patient safety. However, it is fraught with challenges around both implementation and acceptance. Additionally, rewarding of performance improvement is not often done, putting into question the efficacy of the process. Physician audit and feedback have been studied extensively and shown to be beneficial in many fields of medicine. Documenting physician performance and sharing individual and group data have been positively linked to changing physician behavior, ultimately leading to improved patient outcomes. Although casual review of one's own performance is often the easiest approach, it is frequently over- or underestimated by self-evaluation. Objective measures are therefore important to provide concrete data on which physicians can act. A fundamental question remains in mammography: Is reporting the information to the physician and accreditation bodies enough, or should there be consequences for the radiologist and/or facility if there is outlier behavior?

Hereditary Gastric and Breast Cancer Syndromes Related to CDH1 Germline Mutation: A Multidisciplinary Clinical Review

E-cadherin (CDH1 gene) germline mutations are associated with the development of diffuse gastric cancer in the context of the so-called hereditary diffuse gastric syndrome, and with an inherited predisposition of lobular breast carcinoma. In 2019, the international gastric cancer linkage consortium revised the clinical criteria and established guidelines for the genetic screening of CDH1 germline syndromes. Nevertheless, the introduction of multigene panel testing in clinical practice has led to an increased identification of E-cadherin mutations in individuals without a positive family history of gastric or breast cancers. This observation motivated us to review and present a novel multidisciplinary clinical approach (nutritional, surgical, and image screening) for single subjects who present germline CDH1 mutations but do not fulfil the classic clinical criteria, namely those identified as-(1) incidental finding and (2) individuals with lobular breast cancer without family history of gastric cancer (GC).

Use of Breast Cancer Screening and Its Association with Later Use of Preventive Services among Medicare Beneficiaries

Purpose To retrospectively assess whether there is an association between screening mammography and the use of a variety of preventive services in women who are enrolled in Medicare. Materials and Methods U.S. Medicare claims from 2010 to 2014 Research Identifiable Files were reviewed to retrospectively identify a group of women who underwent screening mammography and a control group without screening mammography in 2012. The screened group was divided into positive versus negative results at screening, and the positive subgroup was divided into false-positive and true-positive findings. Multivariate logistic regression models and inverse probability of treatment weighting were used to examine the relationship between screening status and the probabilities of undergoing Papanicolaou test, bone mass measurement, or influenza vaccination in the following 2 years. Results The cohort consisted of 555 705 patients, of whom 185 625 (33.4%) underwent mammography. After adjusting for patient demographics, comorbidities, geographic covariates, and baseline preventive care, women who underwent index screening mammography (with either positive or negative results) were more likely than unscreened women to later undergo Papanicolaou test (odds ratio [OR], 1.49; 95% confidence interval: 1.40, 1.58), bone mass measurement (OR, 1.70; 95% confidence interval: 1.63, 1.78), and influenza vaccine (OR, 1.45; 95% confidence interval: 1.37, 1.53). In women who had not undergone these preventive measures in the 2 years before screening mammography, use of these three services after false-positive findings at screening was no different than after true-negative findings at screening. Conclusion In beneficiaries of U.S. Medicare, use of screening mammography was associated with higher likelihood of adherence to other preventive guidelines, without a negative association between false-positive results and cervical cancer screening.

The Long-Term Effectiveness and Cost Effectiveness of Organized versus Opportunistic Screening for Breast Cancer in Austria

BACKGROUND

In 2014, Austrian health authorities implemented an organized breast cancer screening program. Until then, there has been a long-standing tradition of opportunistic screening.

OBJECTIVES

To evaluate the cost-effectiveness of organized screening compared with opportunistic screening, as well as to identify factors influencing the clinical and economic outcomes.

METHODS

We developed and validated an individual-level state-transition model and assessed the health outcomes and costs of organized and opportunistic screening for 40-year-old asymptomatic women. The base-case analysis compared a scenario involving organized biennial screening with a scenario reflecting opportunistic screening practice for an average-risk woman aged 45 to 69 years. We applied an annual discount rate of 3% and estimated the incremental cost-effectiveness ratio in terms of the cost (2012 euros) per life-year gained (LYG) from a health care perspective. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainty.

RESULTS

Compared with opportunistic screening, an organized program yielded on average additional 0.0118 undiscounted life-years (i.e., 4.3 days) and cost savings of €41 per woman. In the base-case analysis, the incremental cost-effectiveness ratio of organized screening was approximately €20,000 per LYG compared with no screening. Assuming a willingness-to-pay threshold of €50,000 per LYG, there was a 70% probability that organized screening would be considered cost-effective. The attendance rate, but not the test accuracy of mammography, was an influential factor for the cost-effectiveness.

CONCLUSIONS

The decision to adopt organized screening is likely an efficient use of limited health care resources in Austria.

Diagnostic performance of contrast-enhanced spectral mammography: Systematic review and meta-analysis

PURPOSE

To estimate sensitivity and specificity of CESM for breast cancer diagnosis.

METHODS

Systematic review and meta-analysis of the accuracy of CESM in finding breast cancer in highly selected women. We estimated summary receiver operating characteristic curves, sensitivity and specificity according to quality criteria with QUADAS-2.

RESULTS

Six hundred four studies were retrieved, 8 of these reporting on 920 patients with 994 lesions, were eligible for inclusion. Estimated sensitivity from all studies was: 0.98 (95% CI: 0.96-1.00). Specificity was estimated from six studies reporting raw data: 0.58 (95% CI: 0.38-0.77). The majority of studies were scored as at high risk of bias due to the very selected populations.

CONCLUSION

CESM has a high sensitivity but very low specificity. The source studies were based on highly selected case series and prone to selection bias. High-quality studies are required to assess the accuracy of CESM in unselected cases.

Lobular breast cancer series: imaging

The limitations of mammography in the detection and evaluation of invasive lobular carcinoma (ILC) have long been recognized, presenting real clinical challenges in treatment planning for these tumors. However, advances in mammography, ultrasound, and magnetic resonance imaging present opportunities to improve the diagnosis and preoperative assessment of ILC. The evidence supporting the performance of each imaging modality will be reviewed, specifically as it relates to the pathology of ILC and its subtypes. Further, we will discuss emerging technologies that may be employed to enhance the detection rate and ultimately result in more effective screening and staging of ILC.

Complete internal audit of a mammography service in a reference institution for breast imaging

Objective

Undertaking of a complete audit of the service of mammography, as recommended by BI-RADS^®, in a private reference institution for breast cancer diagnosis in the city of São Paulo, SP, Brazil, and comparison of results with those recommended by the literature.

Materials and Methods

Retrospective, analytical and cross-sectional study including 8,000 patients submitted to mammography in the period between April 2010 and March 2011, whose results were subjected to an internal audit. The patients were followed-up until December 2012.

Results

The radiological classification of 7,249 screening mammograms, according to BI-RADS, was the following: category 0 (1.43%), 1 (7.82%), 2 (80.76%), 3 (8.35%), 4 (1.46%), 5 (0.15%) and 6 (0.03%). The breast cancer detection ratio was 4.8 cases per 1,000 mammograms. Ductal carcinoma in situ was found in 22.8% of cases. Positive predictive values for categories 3, 4 and 5 were 1.3%, 41.3% and 100%, respectively. In the present study, the sensitivity of the method was 97.1% and specificity, 97.4%.

Conclusion

The complete internal audit of a service of mammography is essential to evaluate the quality of such service, which reflects on an early breast cancer detection and reduction of mortality rates.

Contrast-enhanced spectral mammography: comparison with conventional mammography and histopathology in 152 women

Objective

The goal of the study was to compare conventional mammography (MG) and contrast-enhanced spectral mammography (CESM) in preoperative women.

Materials and Methods

The study was approved by the local Ethics Committee and all participants provided informed consent. The study included 152 consecutive patients with 173 breast lesions diagnosed on MG or CESM. All MG examinations and consults were conducted in one oncology centre. Non-ionic contrast agent, at a total dose of 1.5 mL/kg body weight, was injected intravenous. Subsequently, CESM exams were performed with a mammography device, allowing dual-energy acquisitions. The entire procedure was done within the oncology centre. Images from low and high energy exposures were processed together and the combination provided an "iodine" image which outlined contrast up-take in the breast.

Results

MG detected 157 lesions in 150 patients, including 92 infiltrating cancers, 12 non-infiltrating cancers, and 53 benign lesions. CESM detected 149 lesions in 128 patients, including 101 infiltrating cancers, 13 non-infiltrating cancers, and 35 benign lesions. CESM sensitivity was 100% (vs. 91% for MG), specificity was 41% (vs. 15% for MG), area under the receiver operating characteristic curve was 0.86 (vs. 0.67 for MG), and accuracy was 80% (vs. 65% for MG) for the diagnosis of breast cancer. Both MG and CESM overestimated lesion sizes compared to histopathology (p < 0.001).

Conclusion

CESM may provide higher sensitivity for breast cancer detection and greater diagnostic accuracy than conventional mammography.

Positive predictive value of additional synchronous breast lesions in whole-breast ultrasonography at the diagnosis of breast cancer: clinical and imaging factors

Purpose:

To evaluate the positive predictive value (PPV) of bilateral whole-breast ultrasonography (BWBU) for detection of synchronous breast lesions on initial diagnosis of breast cancer and evaluate factors affecting the PPV of BWBU according to varying clinicoimaging factors.

Methods:

A total of 75 patients who had synchronous lesions with pathologic confirmation at the initial diagnosis of breast cancer during January 2007 and December 2007 were included. The clinical factors of the patients were evaluated. One observer retrospectively reviewed the imaging studies of the index breast cancer lesion and the synchronous lesion. The PPV for additional biopsy was calculated for BWBU and various clinical and imaging factors affecting the PPV for BWBU were evaluated.

Results:

The overall PPV for additional biopsy was 25.7% (18 of 70). The PPV for synchronous lesions detected both on mammography and BWBU, and detected only on BWBU, was 76.9% (10 of 13) and 14.3% (7 of 49), respectively. There was no clinical factor affecting the PPV for BWBU. Among the imaging factors, ipsilateral location of the synchronous lesion to the index lesion (P=0.06) showed a marginal statistically significant correlation with malignancy in the synchronous breast lesion. A mass with calcification on mammography presentation (P<0.01), presence of calcification among the ultrasonography findings (P<0.01), and high Breast Imaging Reporting and Data System final assessment (P<0.01) were imaging factors that were associated with malignancy in the additional synchronous lesion.

Conclusion:

BWBU can detect additional synchronous malignancy at the diagnosis of breast cancer with a relatively high PPV, especially when mammography findings are correlated with ultrasonographic findings.

Mammography: a review of records in the Department of Radiology at a National Referral Hospital in Uganda

Introduction

Breast cancer is one of the leading cancers amongst women world-wide. Although mortality has been reduced and survival rates increased in developed countries, mortality rates from breast cancer are still a major health challenge for many developing countries. In Uganda, there are no screening programmes and in many cases mammography is used for diagnostic purposes. The purpose of this study was to describe the clinical presentations and mammographic breast density patterns amongst women that presented to the radiology department for mammography at a national referral hospital.

Methods

This was a retrospective study carried out at Mulago Hospital in Uganda between January 2011 and January 2012. Records for patients who had mammography during this period were reviewed.

Results

The total number of patients was 382 with a mean age of 46 years. Majority presented with breast pain and masses. Mammograms done were normal in majority of the women with fatty breast density dominating. In Uganda, mammography was mainly performed for diagnostic purposes.

Conclusion

There is no mammography screening programme in Uganda and many women cannot access the service due to its limited availability and costs despite its significance in breast cancer management. There is therefore need for governments in Uganda, but in other areas as well to support regular mammography screening as a way of reducing mortality from breast cancer.

Detection of breast cancer in asymptomatic and symptomatic groups using computer-aided detection with full-field digital mammography

Purpose

We aimed to determine the sensitivity of computer-aided detection (CAD) applied to digital mammography in asymptomatic and symptomatic breast cancer patients.

Methods

We retrospectively analyzed digital mammography and CAD images from 210 patients diagnosed with breast cancer. The patients were divided into symptomatic and asymptomatic groups. The sensitivity of CAD in both groups was assessed in relation to breast tissue density, histopathological type of breast cancer, and tumor size.

Results

The detection rate of the CAD system was 87.8% in the asymptomatic group. The sensitivity in different tissue densities was 100% in fatty breasts (P1), 88.9% with scattered fibroglandular densities (P2), 94.4% in heterogeneously dense breasts (P3), and 66.7% in extremely dense breasts (P4). The detection rate of the CAD system in the symptomatic group was 87.2%, and the sensitivity was 90.5%, 90%, 86.6%, and 75% in P1-P4 breasts, respectively. In the asymptomatic group, the CAD system detected 90.3% of invasive ductal carcinomas, not otherwise specified (IDC-NOS) and 88.9% of ductal carcinomas in situ (DCIS), but did not detect other types of malignancy. In the symptomatic group, the CAD system detected 88.2% of IDC-NOS, 88.9% of DCIS and 75% of other types of malignancy. When analyzed according to tumor size, the sensitivity of CAD in the asymptomatic and symptomatic groups was 82.6% and 83.3% for tumors <1 cm, 76.5% and 82.4% for tumors between 1 and 2 cm, and 91.7% and 89% in tumors >2 cm.

Conclusion

The sensitivity of CAD was low in P4 breasts and high for tumors larger than 2 cm, with no statistically significant differences between the asymptomatic and symptomatic groups for IDC-NOS and DCIS. CAD showed greater sensitivity for other neoplasms in symptomatic patients.

Clinical utility of breast magnetic resonance imaging in patients presenting with primary breast cancer

Since magnetic resonance imaging (MRI) of the breast has been shown to be sensitive in identifying the extent of the primary tumor and other foci of cancer, we examined its clinical utility in the surgical management of breast cancer patients. From January 2004 to April 2007, 117 patients with newly diagnosed breast cancer underwent bilateral MRI prior to definitive surgical management. Additional lesions were found in 27 patients (23.1%) in the ipsilateral breast and 19 patients (16.2%) in the contralateral breast. Twelve patients (10.3%) had more than one new lesion identified. Six patients (5.1%) had a larger area of tumor than detected by mammography or ultrasound. Additional biopsies were performed in 27 patients (23.1%). Additional foci of cancer were identified in 17 patients (14.5%): 12 (10.2%) in the ipsilateral breast and 5 (4.3%) in the contralateral breast. This information changed the clinical management in 23 cases (19.7%). Further studies are needed to confirm the benefits of MRI relative to its costs and to further identify the appropriate patients to undergo this imaging procedure.

Time for a re-evaluation of mammography in the young? Results of an audit of mammography in women younger than 40 in a resource restricted environment

Mammography in younger women is considered to be of limited value. In a resource restricted environment without access to magnetic resonance imaging (MRI) and with a high incidence of breast cancer in the young, mammography remains an important diagnostic tool. Recent technical advances and better regulation of mammography make a reassessment of its value in these conditions necessary. Data of all the mammograms performed at a tertiary hospital and private breast clinic between January 2003 and July 2009 in women less than 40 years of age were collected. Indications were the presence of a mass, follow-up after primary cancer therapy, and screening for patients perceived at high risk due to a family history or the presence of atypical hyperplasia. Data acquired were as follows: Demographics, prior breast surgery, indication for mammography, outcome of mammography, diagnostic procedures, and their results. Of 2,167 mammograms, 393 were performed for a palpable mass, diagnostic mammography. In these, the overall cancer detection rate was 40%. If the mammography was reported as breast imaging reporting and data system (BIRADS(®)) 5 versus BIRADS(®) 3 and 4 versus BIRADS(®) 1 and 2, a final diagnosis of malignancy was established in 96, 48, and 5%, respectively. Of 367 mammograms done for the follow-up after primary treatment of breast cancer, seven cancers were diagnosed for a detection rate of 1.9%. Of 1,312 mammograms performed for screening, the recall rate was 4%; the biopsy rate 2%, and the cancer diagnosis rate 3/1,000 examinations. In contrast to past series, this series has shown that recent advances in mammography have made it a useful tool in the management of breast problems in young women, notably in a resource-restricted environment. Women for screening should be selected carefully.

Surgical mammography reporting in a limited resource environment

BACKGROUND

Lack of resources and dedicated breast radiology has forced professionals other than radiologists to read mammography. We report a series of surgeon-read mammography in a developing country.

METHODS

Data were collected prospectively form January 2003 to June 2008 for all mammography performed at a tertiary hospital. The data acquired were demographics, previous treatment for breast pathology, and indication for and outcome of mammography, including diagnostic procedures and their results. The results were benchmarked against standard performance indicators.

RESULTS

Of 8,743 mammograms performed, 1,468 were for palpable lumps; the cancer diagnosis rate was 640 per 1,000 investigations (for 885 of these reported as compatible with malignancy, the cancer diagnosis rate was 95%; for 183 reported as indeterminate 60%, for 400 reported as benign/no abnormality 4%). Of 4,998 cancer follow-up mammograms, the cancer diagnosis rate was 15 per 1,000. For 76 of these reported as compatible with malignancy, the cancer diagnosis rate was 67%, for 161 reported as indeterminate, the biopsy rate was 36%, and cancer diagnosis rates of biopsy was 41%. Of 75 cancers diagnosed, 26 were locally recurrent after breast conservation and 49 new contralateral primaries, 84% of these were stage 0-I. Of 2,001 mammograms performed for screening, the biopsy rate was 4.5% and the cancer diagnosis rate of biopsy was 27%; the overall cancer diagnosis rate was 11 per 1,000 examinations; 96% of these were stage 0-1.

CONCLUSIONS

Dedicated breast surgeons are equally proficient at mammography interpretation as radiologists. In resource-restricted environments, nonavailability of dedicated breast radiologists should not preclude development of breast units.

Magnetic Resonance Imaging (MRI) and Spectroscopy (MRS) in Breast Cancer

Breast cancer is a major health problem in women and early detection is of prime importance. Breast magnetic resonance imaging (MRI) provides both physical and physiologic tissue features that are useful in discriminating malignant from benign lesions. Contrast enhanced MRI is valuable for diagnosis of small tumors in dense breast and the structural and kinetic parameters improved the specificity of diagnosing benign from malignant lesions. It is a complimentary modality for preoperative staging, to follow response to therapy, to detect recurrences and for screening high risk women. Diffusion, perfusion and MR elastography have been applied to breast lesion characterization and show promise.

In-vivo MR spectroscopy (MRS) is a valuable method to obtain the biochemical status of normal and diseased tissues. Malignant tissues contain high concentration of choline containing compounds that can be used as a biochemical marker. MRS helps to increase the specificity of MRI in lesions larger than 1cm and to monitor the tumor response. Various MR techniques show promise primarily as adjunct to the existing standard detection techniques, and its acceptability as a screening method will increase if specificity can be improved. This review presents the progress made in different MRI and MRS techniques in beast cancer management.

Breast Cancer: Pre- and Postoperative Imaging for Staging

Mammography is considered the "gold standard" in the evaluation of the breast from an imaging perspective. Multiple studies have demonstrated the benefit of mammography in detecting smaller cancers, leading to identification of early-stage breast cancers, which largely accounts for decreased mortality from breast cancer and the increased rate of breast conservation. Identification of a suspicious lesion on a mammogram prompts further evaluation including additional mammographic views, ultrasound examination, and biopsy. Recently, MRI and positron emission tomography are being offered as adjuncts to the preoperative workup to better stage the patient; however, there is still controversy over the most appropriate use of these modalities.

Performance Parameters for Screening and Diagnostic Mammography in a Community Practice: Are There Differences Between Specialists and General Radiologists?

OBJECTIVE

The purpose of this study was to compare the performance of general radiologists in interpretation of mammograms with that of breast imaging specialists in a high-volume community hospital-based private practice.

MATERIALS AND METHODS

A retrospective observational study was conducted with data prospectively collected over a 5-year period in a community hospital-based practice in which 106,405 screening and 52,149 diagnostic mammograms were performed. The performance of three radiologists specializing in breast imaging was compared with that of six general radiologists. The following data were extracted and analyzed: recall rate, biopsy recommendation rate, and cancer detection rate. Statistical analysis was performed with a chi-square test and two-tailed calculation of p values.

RESULTS

The recall rates of the specialists and generalists were nearly the same at 6.5% and 6.7%, respectively. The biopsy recommendation rate at recall from screening examinations was nearly the same for generalists and specialists (1.2% and 1.1%, respectively; p = 0.4504). This rate also was similar for diagnostic examinations (8.5% for generalists; 8.4% for specialists; p = 0.4086). The cancer detection rate in the screening setting was slightly higher for specialists than for generalists: 2.5 and 2.0 cancers per 1,000 cases, respectively (p = 0.0614). The cancer detection rate in the diagnostic setting was 24.2% higher among specialists (20.0 cancers per 1,000 cases) compared with generalists (16.1 cancers per 1,000 cases) (p = 0.0177).

CONCLUSION

The only statistically significant difference between generalists and specialists was in cancer detection rate among patients undergoing diagnostic mammography. No statistically significant difference was identified between the two groups in terms of recall rate, biopsy recommendation rate, or percentage of favorable-prognosis cases of cancer detected. There was a trend toward greater cancer detection by specialists in the screening setting.

Nonmammographic Evaluation of the Extent of Breast Carcinoma

The role of the breast imager has evolved beyond detecting breast cancer. With emphasis on management with breast conservation therapy, it has become imperative to image the patient preoperatively to adequately determine tumor size and to establish the presence or absence of multifocal, multicentric, or contralateral malignancy. The focus of this article was to provide a review of the current literature examining nonmammographic modalities available to the radiologist to thoroughly evaluate the newly diagnosed breast cancer patient. Our emphasis will be on breast ultrasound and magnetic resonance imaging (MRI). Specific topics discussed include the role, efficacy, and availability of these modalities in the assessment of ductal carcinoma in situ (DCIS) and invasive carcinoma. Mammography remains the standard for the evaluation of the extent of DCIS. However, ultrasound and MRI have been shown to be invaluable adjuncts in the evaluation of the patient with invasive carcinoma, especially those who are considering breast conservation therapy.

Computer-Aided Detection and Diagnosis of Breast Cancer

The use of computer-aided detection (CAD) with film or digital mammography is now widely regarded as the standard of practice in mammography and has been shown to increase the rate of breast cancer detection. There are inherent limitations in 2D mammography, and new technologies involving 2D and 3D imaging with X-rays, ultrasound, and MRI are in use or under investigation. CAD can aid in the reduction of oversight error for these modalities and has the potential to assist the physician in unifying the interpretation across alternative modalities. We believe the result will be improved sensitivity and specificity due to both improved detection and diagnosis.

Prospective screening study of 0.5 Tesla dedicated magnetic resonance imaging for the detection of breast cancer in young, high-risk women

Background

Evidence-based screening guidelines are needed for women under 40 with a family history of breast cancer, a BRCA1 or BRCA2 mutation, or other risk factors. An accurate assessment of breast cancer risk is required to balance the benefits and risks of surveillance, yet published studies have used narrow risk assessment schemata for enrollment. Breast density limits the sensitivity of film-screen mammography but is not thought to pose a limitation to MRI, however the utility of MRI surveillance has not been specifically examined before in women with dense breasts. Also, all MRI surveillance studies yet reported have used high strength magnets that may not be practical for dedicated imaging in many breast centers. Medium strength 0.5 Tesla MRI may provide an alternative economic option for surveillance.

Methods

We conducted a prospective, nonrandomized pilot study of 30 women age 25–49 years with dense breasts evaluating the addition of 0.5 Tesla MRI to conventional screening. All participants had a high quantitative breast cancer risk, defined as ≥ 3.5% over the next 5 years per the Gail or BRCAPRO models, and/or a known BRCA1 or BRCA2 germline mutation.

Results

The average age at enrollment was 41.4 years and the average 5-year risk was 4.8%. Twenty-two subjects had BIRADS category 1 or 2 breast MRIs (negative or probably benign), whereas no category 4 or 5 MRIs (possibly or probably malignant) were observed. Eight subjects had BIRADS 3 results, identifying lesions that were "probably benign", yet prompting further evaluation. One of these subjects was diagnosed with a stage T1aN0M0 invasive ductal carcinoma, and later determined to be a BRCA1 mutation carrier.

Conclusion

Using medium-strength MRI we were able to detect 1 early breast tumor that was mammographically undetectable among 30 young high-risk women with dense breasts. These results support the concept that breast MRI can enhance surveillance for young high-risk women with dense breasts, and further suggest that a medium-strength instrument is sufficient for this application. For the first time, we demonstrate the use of quantitative breast cancer risk assessment via a combination of the Gail and BRCAPRO models for enrollment in a screening trial.

Diagnostic mammography performance and race: outcomes in Black and White women

BACKGROUND

A previous study compared the performance (sensitivity, specificity, positive predictive value, and cancer detection rate) of screening mammography in Black and White women. No study, to the authors' knowledge, has evaluated the difference in the performance of diagnostic mammography between Black and White women.

METHODS

Univariate analysis was used to evaluate differences in characteristics and cancers between Black and White women. Stratified and adjusted logistic regression analyses were used to test the association of Black and White race with performance measures of diagnostic mammography.

RESULTS

The sensitivity of diagnostic mammography was higher (91% vs. 84%) and specificity was lower (86% vs. 90%) among Black women compared with White women. After controlling for age, density, self-reported breast problems, and previous mammography, sensitivity was significantly higher (odds ratio [OR] = 1.82, 95% confidence interval [CI] = 1.22-2.80) and specificity was significantly lower (OR = 0.75, 95% CI = 0.70-0.81) among Black women. The crude cancer detection rate of mammography was higher for Black women (42.6/1000) than for White women (31.0/1000) and Black women had a higher proportion of cancers that were > 2.0 cm (57.4% vs. 46.2%) that were more often poorly differentiated (61.7% vs. 49.3%) and were more often estrogen-receptor and progesterone-receptor negative.

CONCLUSIONS

Black women have lower specificity of diagnostic mammography and, consequently, more unnecessary workups than White women. Black women have higher sensitivity of diagnostic mammography, with cancers that are larger and more advanced than White women. Delay in responding to signs and symptoms would explain the size and later stage. However, more research is needed to understand the biologic differences of breast cancer characteristics between Black and White women.

Breast self-examination: self-reported frequency, quality, and associated outcomes

BACKGROUND

There is little information on the quality of breast self-examination (BSE) and associated outcomes.

METHOD

We conducted a retrospective cohort study of 27,421 women enrolled in a Pacific Northwest health plan. We linked responses regarding BSE quality from a questionnaire to subsequent screening and diagnostic efforts.

RESULTS

A total of 75% of the women performed BSE. We rated BSE quality as adequate in 27%. Women who reported higher BSE duration, frequency, and quality were more likely to have diagnostic mammograms. Participants ultimately diagnosed with breast cancer (N = 300) were significantly less likely to report performing BSE. Tumor size and stage were not associated with BSE behavior.

CONCLUSION

A high proportion of women perform BSE, but few do so adequately. We found no evidence for benefit of BSE. It is time to ask whether systematic BSE performance should continue to be encouraged.

Auditoria em centro de diagnóstico mamário para detecção precoce de câncer de mama

OBJETIVO: Este trabalho apresenta o modelo de auditoria nos resultados das mamografias do Centro de Diagnóstico Mamário da Santa Casa da Misericórdia do Rio de Janeiro. MATERIAIS E MÉTODOS: No período de maio de 1997 a setembro de 1998, foram realizadas 2.000 mamografias, sendo 1.570 em mulheres assintomáticas, cujos resultados foram objeto da auditoria. RESULTADOS: As mamografias das 1.570 mulheres assintomáticas foram classificadas em: categoria 1 - 1.362 casos; categoria 2 - 9 casos; categoria 3 - 95 casos; categoria 4 - 24 casos; categoria 5 - 6 casos; categoria 0 - 74 casos. Dos 199 exames anormais (categorias 0, 3, 4 e 5), foram acompanhadas 107 mulheres (54%) e perdidas 92 mulheres (46%). Os 107 casos incluídos no trabalho tiveram a seguinte classificação: categoria 3 - 48 casos; categoria 4 - 18 casos; categoria 5 - 4 casos; categoria 0 - 37 casos. Dos 48 casos categoria 3, nenhum caso de câncer foi encontrado; dos 18 casos categoria 4, dois casos de câncer foram encontrados; dos quatro casos categoria 5, todos foram diagnosticados câncer; dos 37 casos categoria 0, um caso de câncer foi encontrado. Os valores de auditoria obtidos foram os seguintes: valor preditivo positivo (baseado no exame com resultado anormal) - 11%; valor preditivo positivo (quando houve recomendação de biópsia) - 31%. A taxa de detecção de câncer, em 1.570 mulheres, foi de sete casos; a sensibilidade foi de 100%; a especificidade foi de 96%; a taxa de reconvocação foi de 4,7%. CONCLUSÃO: Todos os resultados obtidos reproduzem os resultados recomendados na literatura.

Evaluation of breast cancer with a computer-aided detection system by mammographic appearance and histopathology

BACKGROUND

The objective of this study was to evaluate the performance of a computer-aided detection (CAD) system for the detection of breast cancer, based on mammographic appearance and histopathology.

METHODS

From 1000 consecutive screening mammograms from women with biopsy-proven breast carcinoma, 273 mammograms were selected randomly for retrospective evaluation by CAD. The sensitivity of the CAD system for breast cancer was assessed from the proportion of masses and microcalcifications detected. The corresponding tumor histopathologies also were evaluated. Normal mammograms (n = 155 patients) were used to determine the false-positive rate of the system.

RESULTS

Of the 273 breast carcinomas, 149 appeared mammographically as masses, and 88 appeared as microcalcifications, including 36 carcinomas that presented as mixed lesions. The CAD system marked 125 of 149 masses correctly (84%), marked 86 of 88 microcalcifications correctly (98%), and marked 32 of 36 of mixed lesions correctly (89%.). The system showed a high sensitivity for the detection of ductal carcinoma in situ (95%; 73 of 77 lesions), invasive lobular carcinoma (95%; 18 of 19 lesions), invasive ductal carcinoma (85%; 125 of 147 lesions), and invasive mammary carcinoma (90%; 27 of 30 lesions). The highest CAD system sensitivity was for all invasive carcinomas that presented as microcalcifications (100%). On normal mammograms, there was an average of 1.3 false-positive CAD marks per image.

CONCLUSIONS

The CAD system correctly marked a large majority of biopsy-proven breast cancers, with a greater sensitivity for lesions with microcalcifications and without significant impact of performance based on tumor histopathology. CAD was highly effective in detecting invasive lobular carcinoma (sensitivity, 95%) and ductal carcinoma in situ (sensitivity, 95%). CAD represents a useful tool for the detection of breast cancer.

A Computer-Aided Detection System for the Evaluation of Breast Cancer by Mammographic Appearance and Lesion Size

OBJECTIVE

The purpose of our study was to evaluate the performance of a computer-aided detection (CAD) system in the detection of breast cancer based on mammographic appearance and lesion size.

CONCLUSION

The CAD system correctly marked most biopsy-proven breast cancers, with a greater sensitivity for microcalcification than for mass lesions but with no significant difference in performance based on cancer size. CAD was highly effective in detecting even the smallest lesions, with a sensitivity of 92% for lesions of 5 mm or less. CAD is a useful tool for the detection of breast cancer.

The Economic Impact of False-Positive Cancer Screens

Objective: Despite the promotion and widespread use of routine cancer screening, little is known about the economic consequences of false-positive screening results. We evaluated the medical and nonmedical costs associated with false-positive prostate, lung, colorectal, and ovarian cancer screens.

Method: We identified 1,087 Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial participants enrolled in a large managed care organization. Medical care use and costs were compiled from automated sources and trial data. Nonmedical care costs to patients with a false-positive lung cancer screen were obtained by telephone interview (n = 98).

Results: Forty-three percent of the study sample incurred at least one false-positive cancer screen. The majority of these patients (83%) received follow-up care. Prior to and after controlling for participant characteristics, significantly higher medical care expenditures in the year following screening were found among those with a false-positive screen. The adjusted mean difference was $1,024 for women and $1,171 for men. Among lung cancer screening patients, few nonmedical care costs were identified beyond the time (mean, 1.5 hours) spent receiving care.

Conclusion: The results here indicate that false-positive results among some available cancer screening tests are relatively common, that patients incurring a false-positive screen tend to receive follow-up testing, and that such follow-up is not without associated medical costs. Along with trials evaluating the health benefits of available cancer screening modalities, investigations into potential undesirable consequences of cancer screening are also warranted.

Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer

PURPOSE

To prospectively assess accuracy of mammography, clinical examination, ultrasonography (US), and magnetic resonance (MR) imaging in preoperative assessment of local extent of breast cancer.

MATERIALS AND METHODS

Institutional review board approval and informed patient consent were obtained. Results of bilateral mammography, US, and contrast-enhanced MR imaging were analyzed from 111 consecutive women with known or suspected invasive breast cancer. Results were correlated with histopathologic findings.

RESULTS

Analysis included 177 malignant foci in 121 cancerous breasts, of which 89 (50%) foci were palpable. Median size of 139 invasive foci was 18 mm (range, 2-107 mm). Mammographic sensitivity decreased from 100% in fatty breasts to 45% in extremely dense breasts. Mammographic sensitivity was highest for invasive ductal carcinoma (IDC) in 89 of 110 (81%) cases versus 10 of 29 (34%) cases of invasive lobular carcinoma (ILC) (P < .001) and 21 of 38 (55%) cases of ductal carcinoma in situ (DCIS) (P < .01). US showed higher sensitivity than did mammography for IDC, depicting 104 of 110 (94%) cases, and for ILC, depicting 25 of 29 (86%) cases (P < .01 for each). US showed higher sensitivity for invasive cancer than DCIS (18 of 38 [47%], P < .001). MR showed higher sensitivity than did mammography for all tumor types (P < .01) and higher sensitivity than did US for DCIS (P < .001), depicting 105 of 110 (95%) cases of IDC, 28 of 29 (96%) cases of ILC, and 34 of 38 (89%) cases of DCIS. In anticipation of conservation or no surgery after mammography and clinical examination in 96 breasts, additional tumor (which altered surgical approach) was present in 30. Additional tumor was depicted in 17 of 96 (18%) breasts at US and in 29 of 96 (30%) at MR, though extent was now overestimated in 12 of 96 (12%) at US and 20 of 96 (21%) at MR imaging. After combined mammography, clinical examination, and US, MR depicted additional tumor in another 12 of 96 (12%) breasts and led to overestimation of extent in another six (6%); US showed no detection benefit after MR imaging. Bilateral cancer was present in 10 of 111 (9%) patients; contralateral tumor was depicted mammographically in six and with both US and MR in an additional three. One contralateral cancer was demonstrated only clinically.

CONCLUSION

In nonfatty breasts, US and MR imaging were more sensitive than mammography for invasive cancer, but both MR imaging and US involved risk of overestimation of tumor extent. Combined mammography, clinical examination, and MR imaging were more sensitive than any other individual test or combination of tests.

Adverse effects of screening mammography

The main risks and other adverse consequences from screening mammography include discomfort from breast compression, patient recall for additional imaging, and false positive biopsies. Although these risks affect a larger number of women than those who benefit from screening, the risks are less consequential than the life-sparing benefits from early detection. Radiation risk, even for multiple screenings, is negligible at current mammography doses. Anxiety before screening or resulting from supplementary imaging work-up, short-term follow-up, cyst aspiration, and biopsy has not dampened the enthusiasm of most women for the value of early detection.

International variation in screening mammography interpretations in community-based programs

BACKGROUND

Variations in mammography interpretations may have important clinical and economic implications. To evaluate international variability in mammography interpretation, we analyzed published reports from community-based screening programs from around the world.

METHODS

A total of 32 publications were identified in MEDLINE that fit the study inclusion criteria. Data abstracted from the publications included features of the population screened, examination technique, and clinical outcomes, including the percentage of mammograms judged to be abnormal, positive predictive value of an abnormal mammogram (PPV(A)), positive predictive value of a biopsy performed (PPV(B)), and percentages of breast cancer patients with ductal carcinoma in situ (DCIS) and minimal disease (DCIS and/or tumor size < or =10 mm). North American screening programs were compared with those from other countries using meta-regression analysis. All statistical tests were two-sided.

RESULTS

Wide ranges were noted for the percentage of mammograms judged to be abnormal (1.2%-15.0%), for PPV(A) (3.4%-48.7%), for PPV(B) (5.0%-85.2%), for percentage diagnosed with DCIS (4.3%-68.1%), and for percentage diagnosed with minimal disease (14.0%-80.6%). The percentage of mammograms judged to be abnormal were 2-4 percentage points higher in North American screening programs than they were in programs from other countries, after adjusting for covariates such as percentage of women who were less than 50 years of age and calendar year in which the mammogram was performed. The percentage of mammograms judged to be abnormal had a negative association with PPV(A) and PPV(B) (both P<.001) and a positive association with the frequency of DCIS cases diagnosed (P =.008) and the number of DCIS cases diagnosed per 1000 screens (P =.024); no consistent relationship was observed with the proportion of breast cancer diagnoses reported as having minimal disease or the number of minimal disease cases diagnosed per 1000 screens.

CONCLUSION

North American screening programs appear to interpret a higher percentage of mammograms as abnormal than programs from other countries without evident benefit in the yield of cancers detected per 1000 screens, although an increase in DCIS detection was noted.

Improvement in sensitivity of screening mammography with computer-aided detection: a multiinstitutional trial

OBJECTIVE

Our study evaluated radiologist detection of breast cancer using a computer-aided detection system.

MATERIALS AND METHODS

Three radiologists reviewed 377 screening mammograms interpreted as showing normal or benign findings 9-24 months before cancer diagnosis from 17 of the 18 participating centers. In 313 cases, study radiologists recommended additional mammographic evaluation. In 177 cases, the area warranting additional workup precisely correlated with the subsequently diagnosed cancer. These 177 missed cancers were evaluated with computer-aided detection. The proportion of radiologists identifying the missed cancers was used to determine radiologist sensitivity without computer-aided detection.

RESULTS

The study radiologists determined that 123 of the 377 missed cancer cases warranted workup. Therefore, 123 additional cancers cases could have been found. The calculated radiologist sensitivity without computer-aided detection was therefore 75.4% (377 / [377 + 123]). Similarly, using the performance of the system on the missed cancers, we estimated that 80 (65.0%) of these 123 missed cancer cases would have been identified with the use of computer-aided detection. Consequently, the estimated sensitivity of radiologists using computer-aided detection was 91.4% ([377 + 80] / [377 + 123])-resulting in a 21.2% ([91.4% / 75.4%] - 1) increase in radiologist sensitivity with computer-aided detection.

CONCLUSION

Use of the computer-aided detection system significantly improved the detection of breast cancer by increasing radiologist sensitivity by 21.2%. Therefore, for every 100,000 women with breast cancer identified without the use of computer-aided detection, an estimated additional 21,200 cancers would be found with the use of computer-aided detection.

Using sonography to screen women with mammographically dense breasts

OBJECTIVE

Mammographically dense breast tissue has been reported both as a cause of false-negative findings on mammography and as an indicator of increased breast cancer risk. We conducted this study to evaluate the role of breast sonography as a second-line screening test in women with mammographically dense breast tissue.

MATERIALS AND METHODS

Between January 2000 and January 2002, 1517 asymptomatic women with dense breasts and normal mammography and physical examination findings underwent physician-performed breast sonography as an adjunct screening test. Within the study group, 318 women had a first-degree family history or personal history of breast cancer. The high-risk subgroup comprised these women. The detection rate of breast cancer in this subgroup was compared with the detection rate in the remaining study population with baseline risk.

RESULTS

Of 1517 women examined, seven breast cancers were diagnosed (cancer-detection rate, 0.46%). Four carcinomas were detected in high-risk women and three in women with baseline risk. The cancer-detection rate in the subgroup of high-risk women was 1.3%, significantly higher (p < 0.04) than the cancer-detection rate of 0.25% in the baseline risk subgroup. All cancers were T1 (range, 4-12 mm; mean, 9.6 mm). Sentinel lymph nodes were negative for cancer in six of seven carcinomas.

CONCLUSION

Screening breast sonography in the population of women with dense breast tissue is useful in detecting small breast cancers that are not detected on mammography or clinical breast examination. The use of sonography as an adjunct to screening mammography in women with increased risk of breast cancer and dense breasts may be especially beneficial.

Measuring the performance of screening mammography in community practice with Medicare claims data

BACKGROUND

Few studies have examined the outcomes of screening mammography in community practice, particularly the extent of false positive exams among older asymptomatic women.

RESEARCH DESIGN

Subjects were female Medicare beneficiaries, age 67 or older, residing in one of eleven SEER areas, with no evidence of breast cancer. Medicare claims data were used to identify their screening mammograms over two time periods, 1993-1995 and 1996-1998, and to measure their use of follow-up diagnostic testing (diagnostic mammography, breast ultrasound and breast biopsy) within three months of the screening mammogram.

RESULTS

There were significant differences among the rates of diagnostic testing for each age group (67-74; 75+ ) by year, but no clear trend toward higher or lower rates over time. Although rates of diagnostic testing differed significantly by geographic region in both time periods 1993-1995 and 1996-1998, estimates of specificity for all regions were within AHRQ clinical practice guidelines (specificity greater than 90%). Specificity significantly improved with the volume of the radiologist's practice for the latter time period (1996-1998) but not for the former (1993-1995).

CONCLUSION

Medicare claims offer an accessible population-based source of data for mammography performance indicators. As such, they offer a low cost method for evaluating individual mammography practices as well as monitoring the impact of reimbursement policies, practice guidelines and laws mandating requirements for accrediting facilities.

Differential value of comparison with previous examinations in diagnostic versus screening mammography

OBJECTIVE

The purpose of our study was to analyze the differences in clinical outcomes of diagnostic and screening mammography depending on whether comparison is made with previous examinations.

MATERIALS AND METHODS

We analyzed 48,281 consecutive mammography examinations for which previous mammography (9825 diagnostic, 38,456 screening) had been performed between 1997 and 2001, collecting data on demographics, whether comparison actually was made with previous examinations, abnormal findings (recall for screening mammography or biopsy recommendation for diagnostic mammography), biopsy yield of cancer, cancer detection rate, size of invasive cancers, axillary nodal status, and cancer stage.

RESULTS

Comparison with previous examinations in the incidence screening setting decreases the recall rate from 4.9% to 3.8% (p < 0.0001) but does not significantly affect the biopsy yield (40-44%, p = 0.56) or the cancer detection rate (5.5-5.2/1000, p = 0.87). In the diagnostic setting, comparison with previous examinations increases the biopsy-recommended rate from 4.3% to 9.4% (p < 0.0001), the biopsy yield from 38% to 51% (p = 0.12), and the overall cancer detection rate from 11/1000 to 39/1000 (p < 0.0001). Comparison with previous examinations is not associated with a significant difference in mean tumor size. However, it is associated with a significant decrease in the frequency of axillary node metastasis and the cancer stage for screening mammography, but not for diagnostic mammography.

CONCLUSION

For screening mammography, comparison with previous examinations significantly decreases false-positive but not true-positive findings and permits detection of cancers at an earlier stage. For diagnostic mammography, comparison with previous examinations increases true-positive findings.

Screening mammograms by community radiologists: variability in false-positive rates

BACKGROUND

Previous studies have shown that the agreement among radiologists interpreting a test set of mammograms is relatively low. However, data available from real-world settings are sparse. We studied mammographic examination interpretations by radiologists practicing in a community setting and evaluated whether the variability in false-positive rates could be explained by patient, radiologist, and/or testing characteristics.

METHODS

We used medical records on randomly selected women aged 40-69 years who had had at least one screening mammographic examination in a community setting between January 1, 1985, and June 30, 1993. Twenty-four radiologists interpreted 8734 screening mammograms from 2169 women. Hierarchical logistic regression models were used to examine the impact of patient, radiologist, and testing characteristics. All statistical tests were two-sided.

RESULTS

Radiologists varied widely in mammographic examination interpretations, with a mass noted in 0%-7.9%, calcification in 0%-21.3%, and fibrocystic changes in 1.6%-27.8% of mammograms read. False-positive rates ranged from 2.6% to 15.9%. Younger and more recently trained radiologists had higher false-positive rates. Adjustment for patient, radiologist, and testing characteristics narrowed the range of false-positive rates to 3.5%-7.9%. If a woman went to two randomly selected radiologists, her odds, after adjustment, of having a false-positive reading would be 1.5 times greater for the radiologist at higher risk of a false-positive reading, compared with the radiologist at lowest risk (95% highest posterior density interval [similar to a confidence interval] = 1.17 to 2.08).

CONCLUSION

Community radiologists varied widely in their false-positive rates in screening mammograms; this variability range was reduced by half, but not eliminated, after statistical adjustment for patient, radiologist, and testing characteristics. These characteristics need to be considered when evaluating false-positive rates in community mammographic examination screening.

Performance parameters for screening and diagnostic mammography: specialist and general radiologists

PURPOSE

To evaluate performance parameters for radiologists in a practice of breast imaging specialists and general diagnostic radiologists who interpret a large series of consecutive screening and diagnostic mammographic studies.

MATERIALS AND METHODS

Data (ie, patient age; family history of breast cancer; availability of previous mammograms for comparison; and abnormal interpretation, cancer detection, and stage 0-I cancer detection rates) were derived from review of mammographic studies obtained from January 1997 through August 2001. The breast imaging specialists have substantially more initial training in mammography and at least six times more continuing education in mammography, and they interpret 10 times more mammographic studies per year than the general radiologists. Differences between specialist and general radiologist performances at both screening and diagnostic examinations were assessed for significance by using Student t and chi(2) tests.

RESULTS

The study involved 47,798 screening and 13,286 diagnostic mammographic examinations. Abnormal interpretation rates for screening mammography (ie, recall rate) were 4.9% for specialists and 7.1% for generalists (P <.001); and for diagnostic mammography (ie, recommended biopsy rate), 15.8% and 9.9%, respectively (P <.001). Cancer detection rates at screening mammography were 6.0 cancer cases per 1,000 examinations for specialists and 3.4 per 1,000 for generalists (P =.007); and at diagnostic mammography, 59.0 per 1,000 and 36.6 per 1,000, respectively (P <.001). Stage 0-I cancer detection rates at screening mammography were 5.3 cancer cases per 1,000 examinations for specialists and 3.0 per 1,000 for generalists (P =.012); and at diagnostic mammography, 43.9 per 1,000 and 27.0 per 1,000, respectively (P <.001).

CONCLUSION

Specialist radiologists detect more cancers and more early-stage cancers, recommend more biopsies, and have lower recall rates than general radiologists.

Provider case volume and outcome in the evaluation and treatment of patients with mammogram-detected breast carcinoma

BACKGROUND

Practice volume may affect the outcome of patients with breast carcinoma. Defining factors that influence the relation of volume and outcome for the diagnosis and treatment of breast carcinoma is important, because breast carcinoma is common, and care is decentralized.

METHODS

Community-wide diagnosis and treatment of mammogram-detected breast carcinoma was examined using claims data from a single insurer representing 25% of the regional population. Among 1001 mammogram-directed breast biopsies, the rate of breast carcinoma diagnosed by stereotactic core needle biopsy (SCNB) or excisional biopsy with needle localization (EBNL) and the rate at which breast-conserving surgery (BCS) was used were analyzed. Outcome and practice volume were examined for surgeons, radiologists, and medical centers.

RESULTS

Two hundred twenty-four tumors were diagnosed by EBNL (604 diagnoses) and SCNB (397 tumors), for a 22.4% positive biopsy rate. The median number of procedures per physician was one. Positive biopsy rates for radiologists, surgeons, and medical centers did not correlate with practice volume. Positive biopsy rates for high-volume physician providers and medical centers ranged from 9% to 46%. The BCS rate was 45% and 64% for surgeons treating one or more than one claim, respectively. Tumor stage and surgeon case volume were the only independent predictors of BCS (P < 0.05).

CONCLUSIONS

There is wide variation in diagnosis and treatment outcomes for patients with mammogram-detected breast carcinoma. Overall, practice volume was correlated with the use of BCS but not with the rate of positive biopsy. A wide variation in the positive biopsy rate among high-volume providers and medical centers suggests that volume of practice is not a surrogate for quality in the diagnosis of breast carcinoma.

Screening mammography: proven benefit, continued controversy

Screening mammography, despite its limitations, remains the best means for diagnosing breast cancer in asymptomatic women. Regarding the continuing controversies concerning the age at which screening should start, evidence supports beginning regular screening at age 40 in women at average risk . Similarly, evidence suggests that the screening interval should be yearly, especially in younger women. Rather than an arbitrary age at which screening should stop, the decision on screening elderly women should be made on an individual basis, taking into account level of health and life expectancy. More work needs to be done on determining the optimum screening strategies for high-risk women. As to the interpretation of screening mammography, a certain level of observer variability and of false-negative and false-positive readings are inherent in the process. These should be kept to a minimum through efforts by the interpreting radiologist to improve performance through auditing of individual results and continuing education. The impact of double reading and computer-aided detection in the interpretation of screening mammograms warrants further evaluation in terms of efficacy and cost-effectiveness. Despite these continuing controversies, mortality from breast cancer in the United States has been decreasing steadily for the past 25 years. The magnitude of the decrease has been reported to range from 8% to 25%. Although some of this decrease may be attributable to improvements in the treatment of breast cancer, early detection through screening mammography has undoubtedly played a role in this mortality reduction. The controversies that surround the issue of screening should not detract from the fact that screening mammography has proved to save lives.

Age-specific accuracy of initial versus subsequent mammography screening: results from the Ghent breast cancer-screening programme

The aim of this study was to determine whether age-related differences in the accuracy of mammography breast cancer screening decrease with repeated examination. Data from the first 8 years (May 1992 to April 1999) of the Ghent breast cancer-screening programme were used for analysis. In total, 28 944 mammography examinations were included. The referral rate, cancer detection rate, positive predictive value, sensitivity and specificity were chosen as performance indicators. Values were calculated for women aged 40-49, 50-59 and 60-69 years, at initial versus subsequent examinations, respectively. For first examinations, overall, performance was much lower for the women in their forties than for the older age groups. On subsequent screening, the effect of age disappeared, as expected, or was even reversed for the positive predictive value and sensitivity of the examination. In the light of the ongoing debate over the eligible age for mammography screening, these results support a universal recommendation beginning at the age of 40 years.

Interpreting data from audits when screening and diagnostic mammography outcomes are combined

OBJECTIVE

The objective of this study was to use mathematic models to aid mammography practices in interpreting outcomes data derived from a combination of screening and diagnostic examinations, and in interpreting diagnostic mammography outcomes data that are not segregated by indication for examination.

MATERIALS AND METHODS

We analyzed outcomes from 51,805 consecutive mammography examinations. Screening and diagnostic examinations were audited separately. Diagnostic examinations were audited by indication for examination. Extrapolating from our known mix of screening (79%) and diagnostic (21%) examinations, we determined expected combined outcomes for various mixes that might be encountered in clinical practice. Similarly, we determined the expected overall diagnostic mammography outcomes for various clinically relevant mixes of indications for examination.

RESULTS

Outcomes vary substantially depending on the mix of screening and diagnostic examinations performed. For example, expected outcomes for practices with screening-diagnostic mixes of 90-10% and 50-50% are, respectively: rate of abnormal findings, 6% versus 11%; rate of positive biopsy findings, 38% versus 42%; cancer detection rate, 10 per 1,000 versus 30 per 1,000; mean invasive cancer size, 14.4 mm versus 16.0 mm; nodal metastasis rate, 8% versus 11%; and rate of stage 0 and stage I cancers, 87% versus 82%. Diagnostic outcomes also vary substantially according to indication for examination, with a higher rate of abnormal findings, a higher rate of positive biopsy findings, and a larger mean invasive cancer size expected for mixes involving a high percentage of workups for palpable lesions.

CONCLUSION

When screening and diagnostic mammography outcomes are not segregated during auditing, and when diagnostic outcomes are not segregated by indication for examination, analysis of combined audit data should be based on extrapolations from known outcomes.

Diagnostic value of radiological breast imaging in a non-screening population

The aim of this study was to assess the diagnostic performance of breast imaging in the diagnosis of breast cancer in a non-screening population. In a consecutive set of patients referred for mammography in one year, the results of palpation and radiological breast imaging were scored on a 5-point grading scale and linked to pathology as gold standard after a follow up period of one year. The diagnostic performance was studied by logistic regression analysis and ROC-curves. There were 1,944 breast examinations in 1,890 patients and 3,816 breasts. Pathology results reported 118 malignancies in 115 women. With a cut-off point between benign and uncertain benign a sensitivity of 89% and a specificity of 98% was found for radiological imaging. ROC-curves showed a significant increase in diagnostic performance when radiology was added to results of palpation and age (p = 0.007). Radiological imaging tests have a large diagnostic value in the detection of breast cancer in addition to palpation and age. A sensitivity close to 100% could be reached.

Increased patient concern after false-positive mammograms: clinician documentation and subsequent ambulatory visits

OBJECTIVE

To measure how often a breast-related concern was documented in medical records after screening mammography according to the mammogram result (normal, or true-negative vs false-positive) and to measure changes in health care utilization in the year after the mammogram.

DESIGN

Cohort study.

SETTING

Large health maintenance organization in New England.

PATIENTS

Group of 496 women with false-positive screening mammograms and a comparison group of 496 women with normal screening mammograms, matched for location and year of mammogram.

MEASUREMENTS AND MAIN RESULTS

1) Documentation in clinicians' notes of patient concern about the breast and 2) ambulatory health care utilization, both breast-related and non-breast-related, in the year after the mammogram. Fifty (10%) of 496 women with false-positive mammograms had documentation of breast-related concern during the 12 months after the mammogram, compared to 1 (0.2%) woman with a normal mammogram (P =.001). Documented concern increased with the intensity of recommended follow-up (P =.009). Subsequent ambulatory visits, not related to the screening mammogram, increased in the year after the mammogram among women with false-positive mammograms, both in terms of breast-related visits (incidence ratio, 3.07; 95% confidence interval [CI], 1.69 to 5.93) and non-breast-related visits (incidence ratio, 1.14; 95% CI, 1.03 to 1.25).

CONCLUSIONS

Clinicians document concern about breast cancer in 10% of women who have false-positive mammograms, and subsequent use of health care services are increased among women with false-positive mammogram results.

Comparison of full-field digital mammography with screen-film mammography for cancer detection: results of 4,945 paired examinations

PURPOSE

To prospectively compare full-field digital mammography (FFDM) with screen-film mammography (SFM) for cancer detection in a screening population.

MATERIALS AND METHODS

At two institutions, 4,945 FFDM examinations were performed in women aged 40 years and older presenting for SFM. Two views of each breast were acquired with each modality. SFM and FFDM images were interpreted independently. Findings detected with either SFM or FFDM were evaluated with additional imaging and, if warranted, biopsy.

RESULTS

Patients in the study underwent 152 biopsies, which resulted in the diagnosis of 35 breast cancers. Twenty-two cancers were detected with SFM and 21 with FFDM. Four were interval cancers that became palpable within 1 year of screening and were considered false-negative findings with both modalities. The difference in cancer detection rate was not significant. FFDM had a significantly lower recall rate (11.5%; 568 of 4,945) than SFM (13.8%; 685 of 4,945) (P <.001, McNemar chi(2) model; P <.03, generalized estimating equations model). The positive biopsy rate for findings detected with FFDM (30%; 21 of 69) was higher than that for findings detected with SFM (19%; 22 of 114), but this difference was not significant.

CONCLUSION

No difference in cancer detection rate has yet been observed between FFDM and SFM. FFDM has so far led to fewer recalls than SFM.

Medical audit of diagnostic mammography examinations: comparison with screening outcomes obtained concurrently

OBJECTIVE

We performed a medical audit of our diagnostic mammography practice and compared clinical outcomes with those of screening mammography examinations performed concurrently.

MATERIALS AND METHODS

We analyzed 46,857 consecutive mammography examinations (10,007 diagnostic, 36,850 screening) from 1997 to 2000, including data on demographics, image interpretation, and biopsy (including size, nodal status, and cancer stage).

RESULTS

The mean age at diagnostic mammography was 55.8 years (mean age at screening mammogram, 59.1 years; p < 0.0001). Among patients who underwent diagnostic examinations, 14.7% had a strong or very strong family history of breast cancer (screening, 11.6%; p < 0.0001). Examination findings were interpreted as abnormal in 14.4% (screening, 5.2%; p < 0.0001). Biopsy was performed in 11.9% (screening, 1.4%; p < 0.0001). Forty-six percent of the biopsies were positive for malignancy (screening, 38%; p < 0.0001). The cancer detection rate was 55 per 1000 (screening, 5/1000; p < 0.0001). Of cancers found, 74.4% were stage 0 or I (screening, 89.3%; p < 0.0001), average size was 18.0 mm (screening, 12.9 mm; p < 0.0001), and axillary nodes were positive for malignancy in 19.9% of invasive cancers (screening, 6.3; p < 0.0001). Differences between diagnostic and screening outcomes were attributable predominantly to the subgroup of diagnostic examinations performed for evaluation of palpable masses.

CONCLUSION

Medical auditing of diagnostic mammography examinations yields substantially different results compared with those of screening examinations, including different patient demographics; higher number of positive biopsies; higher cancer detection rates; and larger, more advanced-stage cancers. Diagnostic and screening data should be segregated during auditing, or if this is not possible, analysis of combined results should be based on known differences between diagnostic and screening outcomes.

Mammography in 53,803 women from the New Hampshire mammography network

PURPOSE

To describe measures of mammography performance in a geographically defined population and evaluate the interpreter's use of the Breast Imaging Reporting and Data System (BI-RADS).

MATERIALS AND METHODS

Mammographic data from 47,651 screening and 6,152 diagnostic examinations from November 1, 1996, to October 31, 1997, were linked to 1,572 pathologic results. Mammographic outcomes were based on BI-RADS assessments and recommendations reported by the interpreting radiologist. The consistency of BI-RADS recommendations was evaluated.

RESULTS

Screening mammography had a sensitivity of 72.4% (95% CI: 66.4%, 78.4%), specificity of 97.3% (95% CI: 97.25%, 97.4%), and positive predictive value of 10.6% (95% CI: 9.1%, 12.2%). Diagnostic mammography had higher sensitivity, 78.1% (95% CI: 71.9%, 84.3%); lower specificity, 89.3% (95% CI: 88.5%, 90.1%); and better positive predictive value, 17.1% (95% CI: 14.5%, 19.8%). The cancer detection rate with screening mammography was 3.3 per 1,000 women, with a biopsy yield of 22.4%, whereas the interval cancer rate was 1. 2 per 1,000. Nearly 80% of screening-detected invasive malignancies were node negative. The recall rate for screening mammography was 8. 3%. Ultrasonography was used in 3.5% of screening and 17.5% of diagnostic examinations. BI-RADS recommendations were generally consistent, except for probably benign assessments.

CONCLUSION

The sensitivity of screening mammography in this population-based sample is lower than expected, although other performance indicators are commendable. BI-RADS "probably benign" assessments are commonly misused.