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Taylor-Phillips S, Jenkinson D, Stinton C, Kunar MA, Watson DG, Freeman K, Mansbridge A, Wallis MG, Kearins O, Hudson S, Clarke A. Fatigue and vigilance in medical experts detecting breast cancer. Proc Natl Acad Sci U S A 2024; 121:e2309576121. [PMID: 38437559 PMCID: PMC10945845 DOI: 10.1073/pnas.2309576121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/19/2023] [Indexed: 03/06/2024] Open
Abstract
An abundance of laboratory-based experiments has described a vigilance decrement of reducing accuracy to detect targets with time on task, but there are few real-world studies, none of which have previously controlled the environment to control for bias. We describe accuracy in clinical practice for 360 experts who examined >1 million women's mammograms for signs of cancer, whilst controlling for potential biases. The vigilance decrement pattern was not observed. Instead, test accuracy improved over time, through a reduction in false alarms and an increase in speed, with no significant change in sensitivity. The multiple-decision model explains why experts miss targets in low prevalence settings through a change in decision threshold and search quit threshold and propose it should be adapted to explain these observed patterns of accuracy with time on task. What is typically thought of as standard and robust research findings in controlled laboratory settings may not directly apply to real-world environments and instead large, controlled studies in relevant environments are needed.
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Affiliation(s)
- Sian Taylor-Phillips
- Division of Health Sciences, Warwick Medical School, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - David Jenkinson
- Division of Health Sciences, Warwick Medical School, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - Chris Stinton
- Division of Health Sciences, Warwick Medical School, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - Melina A. Kunar
- Department of Psychology, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - Derrick G. Watson
- Department of Psychology, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - Alice Mansbridge
- Division of Health Sciences, Warwick Medical School, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - Matthew G. Wallis
- Cambridge Breast Unit and National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, CambridgeCB2 0QQ, United Kingdom
| | - Olive Kearins
- Screening Quality Assurance Service, National Health Service (NHS) England, BirminghamB2 4HQ, United Kingdom
| | - Sue Hudson
- Peel and Schriek Consulting Limited, London NW3 4QG, United Kingdom
| | - Aileen Clarke
- Division of Health Sciences, Warwick Medical School, University of Warwick, CoventryCV4 7AL, United Kingdom
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Freeman K, Mansbridge A, Stobart H, Clements K, Wallis MG, Pinder SE, Kearins O, Shaaban AM, Kirwan CC, Wilkinson LS, Webb S, O'Sullivan E, Jenkins J, Wright S, Taylor K, Bailey C, Holcombe C, Wyld L, Edwards K, Jenkinson DJ, Sharma N, Provenzano E, Hilton B, Stallard N, Thompson AM, Taylor-Phillips S. Evidence-informed recommendations on managing breast screening atypia: perspectives from an expert panel consensus meeting reviewing results from the Sloane atypia project. Br J Radiol 2024; 97:324-330. [PMID: 38265306 DOI: 10.1093/bjr/tqad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/27/2023] [Accepted: 12/13/2023] [Indexed: 01/25/2024] Open
Abstract
Evidence-based clinical guidelines are essential to maximize patient benefit and to reduce clinical uncertainty and inconsistency in clinical practice. Gaps in the evidence base can be addressed by data acquired in routine practice. At present, there is no international consensus on management of women diagnosed with atypical lesions in breast screening programmes. Here, we describe how routine NHS breast screening data collected by the Sloane atypia project was used to inform a management pathway that maximizes early detection of cancer and minimizes over-investigation of lesions with uncertain malignant potential. A half-day consensus meeting with 11 clinical experts, 1 representative from Independent Cancer Patients' Voice, 6 representatives from NHS England (NHSE) including from Commissioning, and 2 researchers was held to facilitate discussions of findings from an analysis of the Sloane atypia project. Key considerations of the expert group in terms of the management of women with screen detected atypia were: (1) frequency and purpose of follow-up; (2) communication to patients; (3) generalizability of study results; and (4) workforce challenges. The group concurred that the new evidence does not support annual surveillance mammography for women with atypia, irrespective of type of lesion, or woman's age. Continued data collection is paramount to monitor and audit the change in recommendations.
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Affiliation(s)
- Karoline Freeman
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Alice Mansbridge
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Hilary Stobart
- Independent Cancer Patients' Voice, London, EC1R 0LL, United Kingdom
| | - Karen Clements
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, Comprehensive Cancer Centre at Guy's Hospital, King's College London, London SE1 9RT, United Kingdom
| | - Olive Kearins
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Abeer M Shaaban
- Breast Unit, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, Birmingham B15 2GW, United Kingdom
| | - Cliona C Kirwan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M20 4BX, United Kingdom
| | - Louise S Wilkinson
- Oxford Breast Imaging Service, Churchill Hospital, Oxford OX3 7LE, United Kingdom
| | - Sharon Webb
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Emma O'Sullivan
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Jacquie Jenkins
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Suzanne Wright
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Kathryn Taylor
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Claire Bailey
- SW London Breast Screening Service, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - Chris Holcombe
- Association of Breast Surgery, Royal College of Surgeons of England, London WC2A 3PE, United Kingdom
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2RX, United Kingdom
| | - Kim Edwards
- Breast Test Wales, Public Health Wales, Llandudno LL30 1QY, United Kingdom
| | - David J Jenkinson
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Nisha Sharma
- Breast Screening Unit, Seacroft Hospital, Leeds LS14 6UH, United Kingdom
| | - Elena Provenzano
- Histopathology and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Bridget Hilton
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Nigel Stallard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77005, United States
| | - Sian Taylor-Phillips
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
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Freeman K, Jenkinson D, Clements K, Wallis MG, Pinder SE, Provenzano E, Stobart H, Stallard N, Kearins O, Sharma N, Shaaban A, Kirwan CC, Hilton B, Thompson AM, Taylor-Phillips S. Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England. BMJ 2024; 384:e077039. [PMID: 38302129 PMCID: PMC10831586 DOI: 10.1136/bmj-2023-077039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To explore how the number and type of breast cancers developed after screen detected atypia compare with the anticipated 11.3 cancers detected per 1000 women screened within one three year screening round in the United Kingdom. DESIGN Observational analysis of the Sloane atypia prospective cohort in England. SETTING Atypia diagnoses through the English NHS breast screening programme reported to the Sloane cohort study. This cohort is linked to the English Cancer Registry and the Mortality and Birth Information System for information on subsequent breast cancer and mortality. PARTICIPANTS 3238 women diagnosed as having epithelial atypia between 1 April 2003 and 30 June 2018. MAIN OUTCOME MEASURES Number and type of invasive breast cancers detected at one, three, and six years after atypia diagnosis by atypia type, age, and year of diagnosis. RESULTS There was a fourfold increase in detection of atypia after the introduction of digital mammography between 2010 (n=119) and 2015 (n=502). During 19 088 person years of follow-up after atypia diagnosis (until December 2018), 141 women developed breast cancer. Cumulative incidence of cancer per 1000 women with atypia was 0.95 (95% confidence interval 0.28 to 2.69), 14.2 (10.3 to 19.1), and 45.0 (36.3 to 55.1) at one, three, and six years after atypia diagnosis, respectively. Women with atypia detected more recently have lower rates of subsequent cancers detected within three years (6.0 invasive cancers per 1000 women (95% confidence interval 3.1 to 10.9) in 2013-18 v 24.3 (13.7 to 40.1) in 2003-07, and 24.6 (14.9 to 38.3) in 2008-12). Grade, size, and nodal involvement of subsequent invasive cancers were similar to those of cancers detected in the general screening population, with equal numbers of ipsilateral and contralateral cancers. CONCLUSIONS Many atypia could represent risk factors rather than precursors of invasive cancer requiring surgery in the short term. Women with atypia detected more recently have lower rates of subsequent cancers detected, which might be associated with changes to mammography and biopsy techniques identifying forms of atypia that are more likely to represent overdiagnosis. Annual mammography in the short term after atypia diagnosis might not be beneficial. More evidence is needed about longer term risks.
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Affiliation(s)
- Karoline Freeman
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - David Jenkinson
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Clements
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
- Comprehensive Cancer Centre at Guy's Hospital, King's College London, London, UK
| | - Elena Provenzano
- Histopathology and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hilary Stobart
- Patient representative, Independent Cancer Patients' Voice, UK
| | - Nigel Stallard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Olive Kearins
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Nisha Sharma
- Breast Screening Unit, Seacroft Hospital, York Road, Leeds, UK
| | - Abeer Shaaban
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Cliona Clare Kirwan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Bridget Hilton
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Sian Taylor-Phillips
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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4
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Klein K, Schafigh DG, Wallis MG, Campbell GM, Malter W, Schömig-Markiefka B, Maintz D, Hellmich M, Krug KB. Assignment of the biological value of solid breast masses based on quantitative evaluations of spectral CT examinations using electron density mapping, Zeffective mapping and iodine mapping. Eur J Radiol 2024; 171:111280. [PMID: 38219351 DOI: 10.1016/j.ejrad.2023.111280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVE We aimed to asses, in a clinical setting, whether the newly available quantitative evaluation of electron density (ED) in spectral CT examinations of the breast provide information on the biological identity of solid breast masses and whether ED maps yield added value to the diagnostic information of iodine maps and Zeff maps calculated from the same CT image datasets. METHODS All patients at the University Breast Cancer Center who underwent a clinically indicated Dual Layer Computed Tomography (DLCT) examination for staging of invasive breast cancer from 2018 to 2020 were prospectively included. Iodine concentration maps, Zeff maps and ED maps were automatically reconstructed from the DLCT datasets. Region of interest (ROI) based evaluations in the breast target lesions and in the aorta were performed semi-automatically in identical anatomical positions using dedicated evaluation software. Case-by-case evaluations were carried independently by 2 of 4 radiologists for each examination, respectively. Statistical analysis derived from the ROIs was done by calculating ROC/AUC curves and Youden indices. RESULTS The evaluations comprised 166 DLCT examinations. In the ED maps the measurements in the breast target lesions yielded Youden cutpoints of 104.0% (reader 1) and 103.8% (reader 2) resulting in AUCs of 0.63 and 0.67 at the empirical cutpoints. The variables "Zeff" and "iodine content" derived from the target lesions showed superior diagnostical results, with a Youden cutpoint of 8.0 mg/ml in the iodine maps and cutpoints of 1.1/1.2 in the Zeff maps the AUCs ranging from 0.84 to 0.85 (p = 0.023 to <0.000). The computational combination of Zeff and ED measurements in the target lesions yielded a slight AUC increase (readers 1: 0.85-0.87; readers 2: 0.84-0.94). The ratios of the measured values in the target lesions normalized to the values measured in the aorta showed comparable results. The AUCs of ED derived from the cutpoints showed inferior results to those derived from the Zeff maps and iodine maps (ED: 0.64 and 0.66 for reader 1 and 2; Zeff: 0.86 for both readers; iodine content: 0.89 and 0.86 for reader 1 and 2, respectively). The computational combination of the ED results and the Zeff measurements did not lead to a clinically relevant diagnostic gain with AUCs ranging from 0.86 to 0.88. CONCLUSIONS Quantitative assessments of Zeff, iodine content and ED all targeting the physical and chemical aspects of iodine uptake in solid breast masses confirmed diagnostically robust cutpoints for the differentiation of benign and malignant findings (Zeff < 7.7, iodine content of <0.8 mg/ml). The evaluations of the ED did not indicate any added diagnostic value beyond the quantitative assessments of Zeff and iodine content. Further research is warranted to develop suitable clinical indications for the use of ED maps.
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Affiliation(s)
- Konstantin Klein
- Dept. of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
| | - Darius Gabriel Schafigh
- Dept. of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany; Dept. of ENT Surgery, University Hospital of Cologne, Cologne, Germany
| | - Matthew G Wallis
- Cambridge Breast Unit, NIHR Cambridge Biomedical Research Centre Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Wolfram Malter
- Breast Cancer Center, Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | | | - David Maintz
- Dept. of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Bioinformatics, Medical Faculty, University of Cologne, Germany
| | - Kathrin Barbara Krug
- Dept. of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany.
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Brettschneider J, Morrison B, Jenkinson D, Freeman K, Walton J, Sitch A, Hudson S, Kearins O, Mansbridge A, Pinder SE, Given-Wilson R, Wilkinson L, Wallis MG, Cheung S, Taylor-Phillips S. Development and quality appraisal of a new English breast screening linked data set as part of the age, test threshold, and frequency of mammography screening (ATHENA-M) study. Br J Radiol 2024; 97:98-112. [PMID: 38263823 PMCID: PMC11027252 DOI: 10.1093/bjr/tqad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES To build a data set capturing the whole breast cancer screening journey from individual breast cancer screening records to outcomes and assess data quality. METHODS Routine screening records (invitation, attendance, test results) from all 79 English NHS breast screening centres between January 1, 1988 and March 31, 2018 were linked to cancer registry (cancer characteristics and treatment) and national mortality data. Data quality was assessed using comparability, validity, timeliness, and completeness. RESULTS Screening records were extracted from 76/79 English breast screening centres, 3/79 were not possible due to software issues. Data linkage was successful from 1997 after introduction of a universal identifier for women (NHS number). Prior to 1997 outcome data are incomplete due to linkage issues, reducing validity. Between January 1, 1997 and March 31, 2018, a total of 11 262 730 women were offered screening of whom 9 371 973 attended at least one appointment, with 139 million person-years of follow-up (a median of 12.4 person years for each woman included) with 73 810 breast cancer deaths and 1 111 139 any-cause deaths. Comparability to reference data sets and internal validity were demonstrated. Data completeness was high for core screening variables (>99%) and main cancer outcomes (>95%). CONCLUSIONS The ATHENA-M project has created a large high-quality and representative data set of individual women's screening trajectories and outcomes in England from 1997 to 2018, data before 1997 are lower quality. ADVANCES IN KNOWLEDGE This is the most complete data set of English breast screening records and outcomes constructed to date, which can be used to evaluate and optimize screening.
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Affiliation(s)
- Julia Brettschneider
- Department of Statistics, University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - Breanna Morrison
- University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - David Jenkinson
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - Karoline Freeman
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - Jackie Walton
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Alice Sitch
- University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Sue Hudson
- Peel & Schriek Consulting Ltd, London, NW3 4QG, United Kingdom
| | - Olive Kearins
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Alice Mansbridge
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, London, WC2R 2LS, United Kingdom
- Comprehensive Cancer Centre at Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, United Kingdom
| | - Rosalind Given-Wilson
- St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - Louise Wilkinson
- Oxford Breast Imaging Centre, Churchill Hospital, Oxford, OX3 7LE, United Kingdom
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, CB2 0QQ, United Kingdom
| | - Shan Cheung
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Sian Taylor-Phillips
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom
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Wheelwright S, Matthews L, Jenkins V, May S, Rea D, Fairbrother P, Gaunt C, Young J, Pirrie S, Wallis MG, Fallowfield L. Recruiting women with ductal carcinoma in situ to a randomised controlled trial: lessons from the LORIS study. Trials 2023; 24:670. [PMID: 37838682 PMCID: PMC10576350 DOI: 10.1186/s13063-023-07703-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/04/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND The LOw RISk DCIS (LORIS) study was set up to compare conventional surgical treatment with active monitoring in women with ductal carcinoma in situ (DCIS). Recruitment to trials with a surveillance arm is known to be challenging, so strategies to maximise patient recruitment, aimed at both patients and recruiting centres, were implemented. METHODS Women aged ≥ 46 years with a histologically confirmed diagnosis of non-high-grade DCIS were eligible for 1:1 randomisation to either surgery or active monitoring. Prior to randomisation, all eligible women were invited to complete: (1) the Clinical Trials Questionnaire (CTQ) examining reasons for or against participation, and (2) interviews exploring in depth opinions about the study information sheets and film. Women agreeing to randomisation completed validated questionnaires assessing health status, physical and mental health, and anxiety levels. Hospital site staff were invited to communication workshops and refresher site initiation visits to support recruitment. Their perspectives on LORIS recruitment were collected via surveys and interviews. RESULTS Eighty percent (181/227) of eligible women agreed to be randomised. Over 40% of participants had high anxiety levels at baseline. On the CTQ, the most frequent most important reasons for accepting randomisation were altruism and belief that the trial offered the best treatment, whilst worries about randomisation and the influences of others were the most frequent most important reasons for declining. Most women found the study information provided clear and useful. Communication workshops for site staff improved knowledge and confidence but only about half said they themselves would join LORIS if eligible. The most common recruitment barriers identified by staff were low numbers of eligible patients and patient preference. CONCLUSIONS Recruitment to LORIS was challenging despite strategies aimed at both patients and site staff. Ensuring that recruiting staff support the study could improve recruitment in similar future trials. TRIAL REGISTRATION ISRCTN27544579, prospectively registered on 22 May 2014.
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Affiliation(s)
- Sally Wheelwright
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9RX, UK.
| | - Lucy Matthews
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9RX, UK
| | - Valerie Jenkins
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9RX, UK
| | - Shirley May
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9RX, UK
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | | | - Claire Gaunt
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Jennie Young
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sarah Pirrie
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Lesley Fallowfield
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9RX, UK
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7
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Cushnan D, Young KC, Ward D, Halling-Brown MD, Duffy S, Given-Wilson R, Wallis MG, Wilkinson L, Lyburn I, Sidebottom R, McAvinchey R, Lewis EB, Mackenzie A, Warren LM. Lessons learned from independent external validation of an AI tool to detect breast cancer using a representative UK data set. Br J Radiol 2023; 96:20211104. [PMID: 36607283 PMCID: PMC9975375 DOI: 10.1259/bjr.20211104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To pilot a process for the independent external validation of an artificial intelligence (AI) tool to detect breast cancer using data from the NHS breast screening programme (NHSBSP). METHODS A representative data set of mammography images from 26,000 women attending 2 NHS screening centres, and an enriched data set of 2054 positive cases were used from the OPTIMAM image database. The use case of the AI tool was the replacement of the first or second human reader. The performance of the AI tool was compared to that of human readers in the NHSBSP. RESULTS Recommendations for future external validations of AI tools to detect breast cancer are provided. The tool recalled different breast cancers to the human readers. This study showed the importance of testing AI tools on all types of cases (including non-standard) and the clarity of any warning messages. The acceptable difference in sensitivity and specificity between the AI tool and human readers should be determined. Any information vital for the clinical application should be a required output for the AI tool. It is recommended that the interaction of radiologists with the AI tool, and the effect of the AI tool on arbitration be investigated prior to clinical use. CONCLUSION This pilot demonstrated several lessons for future independent external validation of AI tools for breast cancer detection. ADVANCES IN KNOWLEDGE Knowledge has been gained towards best practice procedures for performing independent external validations of AI tools for the detection of breast cancer using data from the NHS Breast Screening Programme.
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Affiliation(s)
| | | | - Dominic Ward
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | - Stephen Duffy
- Queen Mary University London, London, United Kingdom
| | | | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Louise Wilkinson
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | | | | | - Emma B Lewis
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | - Lucy M Warren
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
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8
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Clements K, Dodwell D, Hilton B, Stevens-Harris I, Pinder S, Wallis MG, Maxwell AJ, Kearins O, Sibbering M, Shaaban AM, Kirwan C, Sharma N, Stobart H, Dulson-Cox J, Litherland J, Mylvaganam S, Provenzano E, Sawyer E, Thompson AM. Cohort profile of the Sloane Project: methodology for a prospective UK cohort study of >15 000 women with screen-detected non-invasive breast neoplasia. BMJ Open 2022; 12:e061585. [PMID: 36535720 PMCID: PMC9764674 DOI: 10.1136/bmjopen-2022-061585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The introduction of breast screening in the UK led to an increase in the detection of non-invasive breast neoplasia, predominantly ductal carcinoma in situ (DCIS), a non-obligatory precursor of invasive breast cancer. The Sloane Project, a UK prospective cohort study of screen-detected non-invasive breast neoplasia, commenced in 2003 to evaluate the radiological assessment, surgical management, pathology, adjuvant therapy and outcomes for non-invasive breast neoplasia. Long-term follow-up and accurate data collection are essential to examine the clinical impact. Here, we describe the establishment, development and analytical processes for this large UK cohort study. PARTICIPANTS Women diagnosed with non-invasive breast neoplasia via the UK National Health Service Breast Screening Programme (NHSBSP) from 01 April 2003 are eligible, with a minimum age of 46 years. Diagnostic, therapeutic and follow-up data collected via proformas, complement date and cause of death from national data sources. Accrual for patients with DCIS ceased in 2012 but is ongoing for patients with epithelial atypia/in situ neoplasia, while follow-up for all continues long term. FINDINGS TO DATE To date, patients within the Sloane cohort comprise one-third of those diagnosed with DCIS within the NHSBSP and are representative of UK practice. DCIS has a variable outcome and confirms the need for longer-term follow-up for screen-detected DCIS. However, the radiology and pathology features of DCIS can be used to inform patient management. We demonstrate validation of follow-up information collected from national datasets against traditional, manual methods. FUTURE PLANS Conclusions derived from the Sloane Project are generalisable to women in the UK with screen-detected DCIS. The follow-up methodology may be extended to other UK cohort studies and routine clinical follow-up. Data from English patients entered into the Sloane Project are available on request to researchers under data sharing agreement. Annual follow-up data collection will continue for a minimum of 20 years.
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Affiliation(s)
- Karen Clements
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Bridget Hilton
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Isabella Stevens-Harris
- Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Sarah Pinder
- Guy's Comprehensive Cancer Centre, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
- School of Cancer and Pharmaceutical Sciences, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Anthony J Maxwell
- Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Olive Kearins
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Mark Sibbering
- Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Abeer M Shaaban
- Department of Histopathology, Queen Elizabeth Hospital Birmingham and University of Birmingham, Birmingham, UK
| | - Cliona Kirwan
- NIHR Manchester Biomedical Research Centre, Manchester, UK
- Division of Cancer Sciences, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Nisha Sharma
- Breast Unit, St James's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | | | | | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elinor Sawyer
- School of Cancer and Pharmaceutical Sciences, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
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9
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Mackenzie A, Thomson EL, Mitchell M, Elangovan P, van Ongeval C, Cockmartin L, Warren LM, Wilkinson LS, Wallis MG, Given-Wilson RM, Dance DR, Young KC. Virtual clinical trial to compare cancer detection using combinations of 2D mammography, digital breast tomosynthesis and synthetic 2D imaging. Eur Radiol 2022; 32:806-814. [PMID: 34331118 DOI: 10.1007/s00330-021-08197-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/07/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study was designed to compare the detection of subtle lesions (calcification clusters or masses) when using the combination of digital breast tomosynthesis (DBT) and synthetic mammography (SM) with digital mammography (DM) alone or combined with DBT. METHODS A set of 166 cases without cancer was acquired on a DBT mammography system. Realistic subtle calcification clusters and masses in the DM images and DBT planes were digitally inserted into 104 of the acquired cases. Three study arms were created: DM alone, DM with DBT and SM with DBT. Five mammographic readers located the centre of any lesion within the images that should be recalled for further investigation and graded their suspiciousness. A JAFROC figure of merit (FoM) and lesion detection fraction (LDF) were calculated for each study arm. The visibility of the lesions in the DBT images was compared with SM and DM images. RESULTS For calcification clusters, there were no significant differences (p > 0.075) in FoM or LDF. For masses, the FoM and LDF were significantly improved in the arms using DBT compared to DM alone (p < 0.001). On average, both calcification clusters and masses were more visible on DBT than on DM and SM images. CONCLUSIONS This study demonstrated that masses were detected better with DBT than with DM alone and there was no significant difference (p = 0.075) in LDF between DM&DBT and SM&DBT for calcifications clusters. Our results support previous studies that it may be acceptable to not acquire digital mammography alongside tomosynthesis for subtle calcification clusters and ill-defined masses. KEY POINTS • The detection of masses was significantly better using DBT than with digital mammography alone. • The detection of calcification clusters was not significantly different between digital mammography and synthetic 2D images combined with tomosynthesis. • Our results support previous studies that it may be acceptable to not acquire digital mammography alongside tomosynthesis for subtle calcification clusters and ill-defined masses for the imaging technology used.
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Affiliation(s)
- Alistair Mackenzie
- National Coordinating Centre for the Physics in Mammography, Royal Surrey NHS Foundation Trust, Guildford, UK.
| | - Emma L Thomson
- National Coordinating Centre for the Physics in Mammography, Royal Surrey NHS Foundation Trust, Guildford, UK
- Department of Physics, University of Surrey, Guildford, UK
| | - Melissa Mitchell
- National Coordinating Centre for the Physics in Mammography, Royal Surrey NHS Foundation Trust, Guildford, UK
- Department of Physics, University of Surrey, Guildford, UK
| | - Premkumar Elangovan
- National Coordinating Centre for the Physics in Mammography, Royal Surrey NHS Foundation Trust, Guildford, UK
| | | | - Lesley Cockmartin
- Department of Imaging and Pathology, Division of Medical Physics and Quality Assessment, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Lucy M Warren
- National Coordinating Centre for the Physics in Mammography, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Louise S Wilkinson
- Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - David R Dance
- National Coordinating Centre for the Physics in Mammography, Royal Surrey NHS Foundation Trust, Guildford, UK
- Department of Physics, University of Surrey, Guildford, UK
| | - Kenneth C Young
- National Coordinating Centre for the Physics in Mammography, Royal Surrey NHS Foundation Trust, Guildford, UK
- Department of Physics, University of Surrey, Guildford, UK
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10
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Maxwell AJ, Hilton B, Clements K, Dodwell D, Dulson-Cox J, Kearins O, Kirwan C, Litherland J, Mylvaganam S, Provenzano E, Pinder SE, Sawyer E, Shaaban AM, Sharma N, Stobart H, Wallis MG, Thompson AM. Unresected screen-detected ductal carcinoma in situ: Outcomes of 311 women in the Forget-Me-Not 2 study. Breast 2022; 61:145-155. [PMID: 34999428 PMCID: PMC8753270 DOI: 10.1016/j.breast.2022.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIM The natural history of ductal carcinoma in situ (DCIS) is poorly understood. The aim of this cohort study was to determine the outcomes of women who had no surgery for screen-detected DCIS in the 6 months following diagnosis. METHODS English breast screening databases were retrospectively searched for women diagnosed with DCIS without invasive cancer at screening and who had no record of surgery within 6 months of diagnosis. These were cross-referenced with cancer registry data. Details of the potentially eligible women were sent to the relevant breast screening units for verification and for completion of data forms detailing clinical, radiological and pathological findings, non-surgical treatment and subsequent clinical course. RESULTS Data for 311 eligible women (median age 62 years) were available. 60 women developed invasive cancer, 56 ipsilateral and 4 contralateral. Ipsilateral invasion risk increased approximately linearly with time for at least 10 years. The 10-year cumulative risk of ipsilateral invasion was 9% (95% CI 4-21%), 39% (24-58%) and 36% (24-50%) for low, intermediate and high grade DCIS respectively and was higher in younger women, in those with larger DCIS lesions and in those with microinvasion. Most invasive cancers that developed were grade 2 or 3. CONCLUSION The findings suggest that active surveillance may be a reasonable alternative to surgery in patients with low grade DCIS but that women with intermediate or high grade disease should continue to be offered surgery. This highlights the importance of reproducible grading of DCIS to ensure patients receive appropriate treatment.
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Affiliation(s)
- Anthony J Maxwell
- Nightingale Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK; Division of Informatics, Imaging & Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PT, UK.
| | - Bridget Hilton
- Public Health England, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Karen Clements
- Public Health England, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK.
| | | | - Olive Kearins
- Public Health England, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Cliona Kirwan
- Nightingale Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PT, UK.
| | - Janet Litherland
- West of Scotland Breast Screening Centre, Nelson Mandela Place, Glasgow, G2 1QY, UK.
| | - Senthurun Mylvaganam
- New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Road, Wolverhampton, WV10 0QP, UK.
| | - Elena Provenzano
- Department of Histopathology (Box 235), Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Sarah E Pinder
- Division of Cancer Studies, King's College London, Guy's Hospital, St Thomas Street, London, SE1 9RT, UK.
| | - Elinor Sawyer
- School of Cancer & Pharmaceutical Sciences, Kings College London, Guy's Cancer Centre, Great Maze Pond, London, SE1 9RT, UK.
| | - Abeer M Shaaban
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Birmingham, B15 2GW, UK.
| | - Nisha Sharma
- Leeds Wakefield Breast Screening Service, Seacroft Hospital, York Road, Leeds, LS14 6UH, UK.
| | - Hilary Stobart
- Independent Cancer Patients' Voice, 17 Woodbridge Street, London, EC1R 0LL, UK.
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK.
| | - Alastair M Thompson
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, 77030, USA.
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11
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Jenkinson D, Freeman K, Clements K, Hilton B, Dulson-Cox J, Kearins O, Stallard N, Wallis MG, Sharma N, Kirwan C, Pinder S, Provenzano E, Shaaban AM, Stobart H, McDonnell S, Thompson AM, Taylor-Phillips S. Breast screening atypia and subsequent development of cancer: protocol for an observational analysis of the Sloane database in England (Sloane atypia cohort study). BMJ Open 2022; 12:e058050. [PMID: 34996804 PMCID: PMC8744119 DOI: 10.1136/bmjopen-2021-058050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The National Health Service (NHS) Breast Screening Programme aims to detect cancer earlier when treatment is more effective but can harm women by over diagnosing and overtreating cancers which would never have become symptomatic. As well as breast cancer, a spectrum of atypical epithelial proliferations (atypia) can also be detected as part of screening. This spectrum of changes, while not cancer, may mean that a woman is more likely to develop breast cancer in the future. Follow-up of atypia is not evidence based. We currently do not know which atypia should be detected to avoid future cancer. This study will explore how atypia develops into breast cancer in terms of number of women, time of cancer development, cancer type and severity, and whether this varies for different types of atypia. METHODS AND ANALYSIS The Sloane cohort study began in April 2003 with ongoing data collection including atypia diagnosed through screening at screening units in the UK. The database for England has 3645 cases (24 September 2020) of epithelial atypia, with follow-up from 1 to 15 years. The outcomes include subsequent invasive breast cancer and the nature of subsequent cancer. Descriptive statistics will be produced. The observed rates of breast cancer at 1, 3 and 6 years for types of atypia will be reported with CIs, to enable comparison to women in the general population. Time to event methods will be used to describe the time to breast cancer diagnosis for the types of atypia, including flexible parametric modelling if appropriate. Patient representatives from Independent Cancer Patients' Voice are included at every stage of the research. ETHICS AND DISSEMINATION The study has received research ethics approval from the University of Warwick Biomedical and Scientific Research Ethics Committee (BSREC 10/20-21, 8 October 2020), Public Health England office for data release approvals (ODR1718_313) and approval from the English Breast Research Advisory Committee (BSPRAC_031). The findings will be disseminated to breast screening clinicians (via journal publication and conference presentation), to the NHS Breast Screening Programme to update their guidelines on how women with atypia should be followed up, and to the general public.
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Affiliation(s)
| | | | - Karen Clements
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Bridget Hilton
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Joanne Dulson-Cox
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Olive Kearins
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Nisha Sharma
- Breast Screening Unit, Seacroft Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cliona Kirwan
- Department of Surgery, The University of Manchester, Manchester, UK
| | - Sarah Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
- Comprehensive Cancer Centre at Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Elena Provenzano
- Histopathology and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Abeer M Shaaban
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
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12
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Healy NA, Parag Y, Wallis MG, Tanner J, Kilburn-Toppin F. Outcomes of male patients attending the symptomatic breast unit: adherence to local and national imaging guidelines and effectiveness of clinical examination and imaging in detecting male breast cancer. Clin Radiol 2021; 77:e64-e74. [PMID: 34716007 DOI: 10.1016/j.crad.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/21/2021] [Indexed: 11/15/2022]
Abstract
AIM To review outcomes of male patients attending the breast unit, evaluate effectiveness of imaging and examination in detecting breast cancer and review adherence to guidelines for male breast imaging. MATERIALS AND METHODS A retrospective review was undertaken of male patients attending Cambridge Breast Unit from 1 January 2015 to 31 December 2019. Patient electronic records and imaging were reviewed to establish demographics, clinical findings, imaging, biopsy, and pathology outcomes. RESULTS Of 1,362 male patients attending the breast unit, 1,028 (75%) had imaging performed. Biopsy was performed in 41 men (3%), with 14 cancers diagnosed (1%). Clinical examination showed 42.7% sensitivity, 99.6% specificity, 54.6% positive predictive value (PPV) and 99.4% negative predictive value (NPV) for detection of cancer. Mammogram demonstrated 84.6% sensitivity, 99.4% specificity, 69.8% PPV, and 99.8% NPV for detection of malignancy. Ultrasound demonstrated 78.6% sensitivity, 98.9% specificity, 73.3% PPV and 99.2% NPV for detection of cancer. Forty-one percent of patients <40 years and 51% < 50 years were imaged, who according to local and Royal College of Radiologists (RCR) guidelines did not require imaging based on age and clinical score. CONCLUSION Male patients account for a small proportion of referrals to the breast unit but generate significant workload. Imaging protocols, incorporating clinical score and age cut-off at 40 years remains robust for detecting malignancy. Clinician awareness of the imaging protocol, and close liaison with radiologists is essential to minimise additional radiology workload.
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Affiliation(s)
- N A Healy
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes' Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Y Parag
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes' Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - M G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes' Hospital, Hills Road, Cambridge, CB2 0QQ, UK; NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - J Tanner
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes' Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - F Kilburn-Toppin
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes' Hospital, Hills Road, Cambridge, CB2 0QQ, UK
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13
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Burnside ES, Warren LM, Myles J, Wilkinson LS, Wallis MG, Patel M, Smith RA, Young KC, Massat NJ, Duffy SW. Quantitative breast density analysis to predict interval and node-positive cancers in pursuit of improved screening protocols: a case-control study. Br J Cancer 2021; 125:884-892. [PMID: 34168297 PMCID: PMC8438060 DOI: 10.1038/s41416-021-01466-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 05/18/2021] [Accepted: 06/10/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This study investigates whether quantitative breast density (BD) serves as an imaging biomarker for more intensive breast cancer screening by predicting interval, and node-positive cancers. METHODS This case-control study of 1204 women aged 47-73 includes 599 cancer cases (302 screen-detected, 297 interval; 239 node-positive, 360 node-negative) and 605 controls. Automated BD software calculated fibroglandular volume (FGV), volumetric breast density (VBD) and density grade (DG). A radiologist assessed BD using a visual analogue scale (VAS) from 0 to 100. Logistic regression and area under the receiver operating characteristic curves (AUC) determined whether BD could predict mode of detection (screen-detected or interval); node-negative cancers; node-positive cancers, and all cancers vs. controls. RESULTS FGV, VBD, VAS, and DG all discriminated interval cancers (all p < 0.01) from controls. Only FGV-quartile discriminated screen-detected cancers (p < 0.01). Based on AUC, FGV discriminated all cancer types better than VBD or VAS. FGV showed a significantly greater discrimination of interval cancers, AUC = 0.65, than of screen-detected cancers, AUC = 0.61 (p < 0.01) as did VBD (0.63 and 0.53, respectively, p < 0.001). CONCLUSION FGV, VBD, VAS and DG discriminate interval cancers from controls, reflecting some masking risk. Only FGV discriminates screen-detected cancers perhaps adding a unique component of breast cancer risk.
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Affiliation(s)
- Elizabeth S Burnside
- Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, WI, USA.
| | - Lucy M Warren
- National Co-ordinating Centre for the Physics of Mammography (NCCPM), Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | - Jonathan Myles
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
| | | | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Mishal Patel
- Scientific Computing, Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | | | - Kenneth C Young
- National Co-ordinating Centre for the Physics of Mammography (NCCPM), Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | - Nathalie J Massat
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
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14
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Boita J, van Engen RE, Mackenzie A, Tingberg A, Bosmans H, Bolejko A, Zackrisson S, Wallis MG, Ikeda DM, Van Ongeval C, Pijnappel R, Broeders M, Sechopoulos I. How does image quality affect radiologists' perceived ability for image interpretation and lesion detection in digital mammography? Eur Radiol 2021; 31:5335-5343. [PMID: 33475774 PMCID: PMC8213590 DOI: 10.1007/s00330-020-07679-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/09/2020] [Accepted: 12/29/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To study how radiologists' perceived ability to interpret digital mammography (DM) images is affected by decreases in image quality. METHODS One view from 45 DM cases (including 30 cancers) was degraded to six levels each of two acquisition-related issues (lower spatial resolution and increased quantum noise) and three post-processing-related issues (lower and higher contrast and increased correlated noise) seen during clinical evaluation of DM systems. The images were shown to fifteen breast screening radiologists from five countries. Aware of lesion location, the radiologists selected the most-degraded mammogram (indexed from 1 (reference) to 7 (most degraded)) they still felt was acceptable for interpretation. The median selected index, per degradation type, was calculated separately for calcification and soft tissue (including normal) cases. Using the two-sided, non-parametric Mann-Whitney test, the median indices for each case and degradation type were compared. RESULTS Radiologists were not tolerant to increases (medians: 1.5 (calcifications) and 2 (soft tissue)) or decreases (median: 2, for both types) in contrast, but were more tolerant to correlated noise (median: 3, for both types). Increases in quantum noise were tolerated more for calcifications than for soft tissue cases (medians: 3 vs. 4, p = 0.02). Spatial resolution losses were considered less acceptable for calcification detection than for soft tissue cases (medians: 3.5 vs. 5, p = 0.001). CONCLUSIONS Perceived ability of radiologists for image interpretation in DM was affected not only by image acquisition-related issues but also by image post-processing issues, and some of those issues affected calcification cases more than soft tissue cases. KEY POINTS • Lower spatial resolution and increased quantum noise affected the radiologists' perceived ability to interpret calcification cases more than soft tissue lesion or normal cases. • Post-acquisition image processing-related effects, not only image acquisition-related effects, also impact the perceived ability of radiologists to interpret images and detect lesions. • In addition to current practices, post-acquisition image processing-related effects need to also be considered during the testing and evaluation of digital mammography systems.
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Affiliation(s)
- Joana Boita
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein 10, 6525, GA, Nijmegen, The Netherlands
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538, SW, Nijmegen, The Netherlands
| | - Ruben E van Engen
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538, SW, Nijmegen, The Netherlands
| | - Alistair Mackenzie
- National Coordinating Centre for the Physics of Mammography, Royal Surrey NHS Foundation Trust, Guildford, GU2 7XX, UK
| | - Anders Tingberg
- Department of Medical Radiation Physics, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502, Malmö, Sweden
| | - Hilde Bosmans
- Department of Imaging and Pathology, Radiology, KUL, Herestraat 49, B-3000, Leuven, Belgium
- Department of Radiology, Radiology, UZ Gasthuisberg, Herestraat 49, B-3000, Leuven, Belgium
| | - Anetta Bolejko
- Department of Medical Imaging and Physiology, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502, Malmö, Sweden
| | - Sophia Zackrisson
- Department of Medical Imaging and Physiology, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502, Malmö, Sweden
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK
| | - Debra M Ikeda
- Department of Radiology, Stanford University School of Medicine, 875 Blake Wilbur Dr, Stanford, CA, 94305, USA
| | - Chantal Van Ongeval
- Department of Radiology, Radiology, UZ Gasthuisberg, Herestraat 49, B-3000, Leuven, Belgium
| | - Ruud Pijnappel
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538, SW, Nijmegen, The Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Mireille Broeders
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538, SW, Nijmegen, The Netherlands
- Department for Health Evidence, Radboud University Medical Center, Geert Grooteplein 10, 6525, GA, Nijmegen, The Netherlands
| | - Ioannis Sechopoulos
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein 10, 6525, GA, Nijmegen, The Netherlands.
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538, SW, Nijmegen, The Netherlands.
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Cooper JA, Jenkinson D, Stinton C, Wallis MG, Hudson S, Taylor-Phillips S. Optimising breast cancer screening reading: blinding the second reader to the first reader's decisions. Eur Radiol 2021; 32:602-612. [PMID: 34117912 PMCID: PMC8660753 DOI: 10.1007/s00330-021-07965-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/02/2021] [Accepted: 03/30/2021] [Indexed: 11/22/2022]
Abstract
Objectives In breast cancer screening, two readers separately examine each woman’s mammograms for signs of cancer. We examined whether preventing the two readers from seeing each other’s decisions (blinding) affects behaviour and outcomes. Methods This cohort study used data from the CO-OPS breast-screening trial (1,119,191 women from 43 screening centres in England) where all discrepant readings were arbitrated. Multilevel models were fitted using Markov chain Monte Carlo to measure whether reader 2 conformed to the decisions of reader 1 when they were not blinded, and the effect of blinding on overall rates of recall for further tests and cancer detection. Differences in positive predictive value (PPV) were assessed using Pearson’s chi-squared test. Results When reader 1 recalls, the probability of reader 2 also recalling was higher when not blinded than when blinded, suggesting readers may be influenced by the other’s decision. Overall, women were less likely to be recalled when reader 2 was blinded (OR 0.923; 95% credible interval 0.864, 0.986), with no clear pattern in cancer detection rate (OR 1.029; 95% credible interval 0.970, 1.089; Bayesian p value 0.832). PPV was 22.1% for blinded versus 20.6% for not blinded (p < 0.001). Conclusions Our results suggest that when not blinded, reader 2 is influenced by reader 1’s decisions to recall (alliterative bias) which would result in bypassing arbitration and negate some of the benefits of double-reading. We found a relationship between blinding the second reader and slightly higher PPV of breast cancer screening, although this analysis may be confounded by other centre characteristics. Key Points • In Europe, it is recommended that breast screening mammograms are analysed by two readers but there is little evidence on the effect of ‘blinding’ the readers so they cannot see each other’s decisions. • We found evidence that when the second reader is not blinded, they are more likely to agree with a recall decision from the first reader and less likely to make an independent judgement (alliterative error). This may reduce overall accuracy through bypassing arbitration. • This observational study suggests an association between blinding the second reader and higher positive predictive value of screening, but this may be confounded by centre characteristics. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-07965-z.
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Affiliation(s)
- Jennifer A Cooper
- Department of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.,Population Health Sciences; Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | - David Jenkinson
- Department of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Chris Stinton
- Department of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals National Health Service Foundation Trust, and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - Sue Hudson
- Peel & Schriek Consulting Limited, London, UK
| | - Sian Taylor-Phillips
- Department of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK. .,Warwick Screening, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
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Boita J, van Engen RE, Mackenzie A, Tingberg A, Bosmans H, Bolejko A, Zackrisson S, Wallis MG, Ikeda DM, van Ongeval C, Pijnappel R, Broeders M, Sechopoulos I. Validation of a candidate instrument to assess image quality in digital mammography using ROC analysis. Eur J Radiol 2021; 139:109686. [PMID: 33819803 DOI: 10.1016/j.ejrad.2021.109686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To validate a candidate instrument, to be used by different professionals to assess image quality in digital mammography (DM), against detection performance results. METHODS A receiver operating characteristics (ROC) study was conducted to assess the detection performance in DM images with four different image quality levels due to different quality issues. Fourteen expert breast radiologists from five countries assessed a set of 80 DM cases, containing 60 lesions (40 cancers, 20 benign findings) and 20 normal cases. A visual grading analysis (VGA) study using a previously-described candidate instrument was conducted to evaluate a subset of 25 of the images used in the ROC study. Eight radiologists that had participated in the ROC study, and seven expert breast-imaging physicists, evaluated this subset. The VGA score (VGAS) and the ROC and visual grading characteristics (VGC) areas under the curve (AUCROC and AUCVGC) were compared. RESULTS No large differences in image quality among the four levels were detected by either ROC or VGA studies. However, the ranking of the four levels was consistent: level 1 (partial AUCROC: 0.070, VGAS: 6.77) performed better than levels 2 (0.066, 6.15), 3 (0.061, 5.82), and 4 (0.062, 5.37). Similarity between radiologists' and physicists' assessments was found (average VGAS difference of 10 %). CONCLUSIONS The results from the candidate instrument were found to correlate with those from ROC analysis, when used by either observer group. Therefore, it may be used by different professionals, such as radiologists, radiographers, and physicists, to assess clinically-relevant image quality variations in DM.
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Affiliation(s)
- Joana Boita
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands; Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands
| | - Ruben E van Engen
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands
| | - Alistair Mackenzie
- National Coordinating Centre for the Physics of Mammography, Royal Surrey NHS Foundation Trust, Guildford, GU2 7XX, UK
| | - Anders Tingberg
- Department of Medical Radiation Physics, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502 Malmö, Sweden
| | - Hilde Bosmans
- Department of Imaging and Pathology, Radiology, KUL, Herestraat 49, Leuven B-3000, Belgium; Department of Radiology, Radiology, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium
| | - Anetta Bolejko
- Department of Medical Imaging and Physiology, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502 Malmö, Sweden
| | - Sophia Zackrisson
- Department of Medical Imaging and Physiology, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502 Malmö, Sweden
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK
| | - Debra M Ikeda
- Department of Radiology, Stanford University School of Medicine, 875 Blake Wilbur Dr, Stanford, CA, 94305, USA
| | - Chantal van Ongeval
- Department of Radiology, Radiology, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium
| | - Ruud Pijnappel
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands; Department of Radiology, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, Utrecht University, the Netherlands
| | - Mireille Broeders
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands; Department for Health Evidence, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands
| | - Ioannis Sechopoulos
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands; Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands.
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17
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Boita J, Bolejko A, Zackrisson S, Wallis MG, Ikeda DM, Van Ongeval C, van Engen RE, Mackenzie A, Tingberg A, Bosmans H, Pijnappel R, Sechopoulos I, Broeders M. Development and content validity evaluation of a candidate instrument to assess image quality in digital mammography: A mixed-method study. Eur J Radiol 2021; 134:109464. [PMID: 33307458 DOI: 10.1016/j.ejrad.2020.109464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To develop a candidate instrument to assess image quality in digital mammography, by identifying clinically relevant features in images that are affected by lower image quality. METHODS Interviews with fifteen expert breast radiologists from five countries were conducted and analysed by using adapted directed content analysis. During these interviews, 45 mammographic cases, containing 44 lesions (30 cancers, 14 benign findings), and 5 normal cases, were shown with varying image quality. The interviews were performed to identify the structures from breast tissue and lesions relevant for image interpretation, and to investigate how image quality affected the visibility of those structures. The interview findings were used to develop tentative items, which were evaluated in terms of wording, understandability, and ambiguity with expert breast radiologists. The relevance of the tentative items was evaluated using the content validity index (CVI) and modified kappa index (k*). RESULTS Twelve content areas, representing the content of image quality in digital mammography, emerged from the interviews and were converted into 29 tentative items. Fourteen of these items demonstrated excellent CVI ≥ 0.78 (k* > 0.74), one showed good CVI < 0.78 (0.60 ≤ k* ≤ 0.74), while fourteen were of fair or poor CVI < 0.78 (k* ≤ 0.59). In total, nine items were deleted and five were revised or combined resulting in 18 items. CONCLUSIONS By following a mixed-method methodology, a candidate instrument was developed that may be used to characterise the clinically-relevant impact that image quality variations can have on digital mammography.
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Affiliation(s)
- Joana Boita
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands; Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands
| | - Anetta Bolejko
- Department of Medical Imaging and Physiology, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502, Malmö, Sweden
| | - Sophia Zackrisson
- Department of Medical Imaging and Physiology, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502, Malmö, Sweden
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK
| | - Debra M Ikeda
- Department of Radiology, Stanford University School of Medicine, 875 Blake Wilbur Dr. Stanford, CA, 94305, USA
| | - Chantal Van Ongeval
- Department of Radiology, Radiology, UZ Gasthuisberg, Herestraat 49, Leuven, B-3000, Belgium
| | - Ruben E van Engen
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands
| | - Alistair Mackenzie
- National Coordinating Centre for the Physics of Mammography, Royal Surrey NHS Foundation Trust, Guildford, GU2 7XX, UK
| | - Anders Tingberg
- Department of Medical Radiation Physics, Translational Medicine Malmö, Lund University, Skåne University Hospital, Carl Bertil Laurells gata 9, SE-20502, Malmö, Sweden
| | - Hilde Bosmans
- Department of Radiology, Radiology, UZ Gasthuisberg, Herestraat 49, Leuven, B-3000, Belgium; Department of Imaging and Pathology, Radiology, KUL, Herestraat 49, Leuven, B-3000, Belgium
| | - Ruud Pijnappel
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands; Department of Radiology, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, Utrecht University, the Netherlands
| | - Ioannis Sechopoulos
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands; Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands
| | - Mireille Broeders
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands; Department for Health Evidence, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands.
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Halling-Brown MD, Warren LM, Ward D, Lewis E, Mackenzie A, Wallis MG, Wilkinson LS, Given-Wilson RM, McAvinchey R, Young KC. OPTIMAM Mammography Image Database: A Large-Scale Resource of Mammography Images and Clinical Data. Radiol Artif Intell 2021; 3:e200103. [PMID: 33937853 PMCID: PMC8082293 DOI: 10.1148/ryai.2020200103] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/03/2020] [Accepted: 10/05/2020] [Indexed: 11/11/2022]
Abstract
Supplemental material is available for this article.
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Affiliation(s)
- Mark D. Halling-Brown
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Lucy M. Warren
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Dominic Ward
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Emma Lewis
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Alistair Mackenzie
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Matthew G. Wallis
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Louise S. Wilkinson
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Rosalind M. Given-Wilson
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Rita McAvinchey
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
| | - Kenneth C. Young
- From the Department of Scientific Computing (M.D.H.B., D.W., E.L.) and National Co-ordinating Centre for the Physics of Mammography (L.M.W., A.M., K.C.Y.), Royal Surrey NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, England; Centre for Vision, Speech and Signal Processing (M.D.H.B., E.L.) and Department of Physics (K.C.Y.), University of Surrey, Guildford, England; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England (M.G.W.); NIHR Cambridge Biomedical Research Centre, Cambridge, England (M.G.W.); Oxford Breast Imaging Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England (L.S.W.); Department of Radiology, St George’s Healthcare NHS Trust, London, England (R.M.G.W.); and Jarvis Breast Screening Centre, Guildford, England (R.M.)
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Shaaban AM, Hilton B, Clements K, Provenzano E, Cheung S, Wallis MG, Sawyer E, Thomas JS, Hanby AM, Pinder SE, Thompson AM. Pathological features of 11,337 patients with primary ductal carcinoma in situ (DCIS) and subsequent events: results from the UK Sloane Project. Br J Cancer 2020; 124:1009-1017. [PMID: 33199800 PMCID: PMC7921398 DOI: 10.1038/s41416-020-01152-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/28/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background The Sloane audit compares screen-detected ductal carcinoma in situ (DCIS) pathology with subsequent management and outcomes. Methods This was a national, prospective cohort study of DCIS diagnosed during 2003–2012. Results Among 11,337 patients, 7204 (64%) had high-grade DCIS. Over time, the proportion of high-grade disease increased (from 60 to 65%), low-grade DCIS decreased (from 10 to 6%) and mean size increased (from 21.4 to 24.1 mm). Mastectomy was more common for high-grade (36%) than for low-grade DCIS (15%). Few (6%) patients treated with breast-conserving surgery (BCS) had a surgical margin <1 mm. Of the 9191 women diagnosed in England (median follow-up 9.4 years), 7% developed DCIS or invasive malignancy in the ipsilateral and 5% in the contralateral breast. The commonest ipsilateral event was invasive carcinoma (n = 413), median time 62 months, followed by DCIS (n = 225), at median 37 months. Radiotherapy (RT) was most protective against recurrence for high-grade DCIS (3.2% for high-grade DCIS with RT compared to 6.9% without, compared with 2.3 and 3.0%, respectively, for low/intermediate-grade DCIS). Ipsilateral DCIS events lessened after 5 years, while the risk of ipsilateral invasive cancer remained consistent to beyond 10 years. Conclusion DCIS pathology informs patient management and highlights the need for prolonged follow-up of screen-detected DCIS.
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Affiliation(s)
- Abeer M Shaaban
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Birmingham, UK.
| | - Bridget Hilton
- Screening Quality Assurance Service, Public Health England, Birmingham, UK
| | - Karen Clements
- Screening Quality Assurance Service, Public Health England, Birmingham, UK
| | - Elena Provenzano
- Addenbrookes Hospital, Cambridge, UK.,Cambridge Breast Unit, and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Shan Cheung
- Screening Quality Assurance Service, Public Health England, Birmingham, UK
| | - Matthew G Wallis
- Addenbrookes Hospital, Cambridge, UK.,Cambridge Breast Unit, and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Elinor Sawyer
- School of Cancer & Pharmaceutical Sciences, King's College London and Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Andrew M Hanby
- Leeds Institute of Medical Research at St. James's, St James's University Hospital, Leeds, UK
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London and Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
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20
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Blanks RG, Wallis MG, Alison RJ, Given-Wilson RM. An analysis of screen-detected invasive cancers by grade in the English breast cancer screening programme: are we failing to detect sufficient small grade 3 cancers? Eur Radiol 2020; 31:2548-2558. [PMID: 32997179 PMCID: PMC7979656 DOI: 10.1007/s00330-020-07276-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 07/31/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Randomised controlled trials have shown a reduction in breast cancer mortality from mammography screening and it is the detection of high-grade invasive cancers that is responsible for much of this effect. We determined the detection rates of invasive cancers by grade, size and type of screen and estimated relative sensitivities with emphasis on grade 3 detection. METHODS This observational study analysed data from over 11 million screening episodes (67,681 invasive cancers) from the English NHS breast screening programme over seven screening years 2009/2010 to 2015/2016 for women aged 45-70. RESULTS At prevalent (first) screens (which are unaffected by screening interval), the detection rate of small (< 15 mm) invasive cancers was 0.95 per 1000 for grade 1, but for grade 3 only 0.30 per 1000. The ratio of small (< 15 mm) to large (≥ 15 mm) cancers was 1.8:1 for grade 1 but reversed to 0.5:1 for grade 3. We estimated that the relative sensitivity for grade 3 invasive cancers was 52% of that for grade 1 and the relative sensitivity for small (< 15 mm) grade 3 only 26% of that for small (< 15 mm) grade 1 invasive cancers. CONCLUSIONS Sensitivity for small grade 3 invasive cancers is poor compared with that for grade 1 and 2 invasive cancers and larger grade 3 malignancies. This observation is likely a limitation of the current technology related to the absence of identifiable mammographic features for small high-grade cancers. Future work should focus on technologies and strategies to improve detection of these clinically most significant cancers. KEY POINTS • The detection of small high-grade invasive cancers is vital to reduce breast cancer mortality. • We estimate the sensitivity for small grade 3 invasive cancers may be only 26% of that of small grade 1 invasive cancers. This is likely to be associated with the non-specific mammographic features for these cancers. • New technologies and appropriate strategies using current technology are required to maximise the detection of small grade 3 invasive cancers.
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Affiliation(s)
- R G Blanks
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford, OX3 7LF, UK.
| | - M G Wallis
- MBCHB Cambridge Breast Unit, and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - R J Alison
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford, OX3 7LF, UK
| | - R M Given-Wilson
- Department of Radiology, St Georges University Hospital Foundation Trust, London, UK
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Rodriguez-Ruiz A, Lång K, Gubern-Merida A, Broeders M, Gennaro G, Clauser P, Helbich TH, Chevalier M, Tan T, Mertelmeier T, Wallis MG, Andersson I, Zackrisson S, Mann RM, Sechopoulos I. Stand-Alone Artificial Intelligence for Breast Cancer Detection in Mammography: Comparison With 101 Radiologists. J Natl Cancer Inst 2020; 111:916-922. [PMID: 30834436 DOI: 10.1093/jnci/djy222] [Citation(s) in RCA: 268] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/06/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Artificial intelligence (AI) systems performing at radiologist-like levels in the evaluation of digital mammography (DM) would improve breast cancer screening accuracy and efficiency. We aimed to compare the stand-alone performance of an AI system to that of radiologists in detecting breast cancer in DM. METHODS Nine multi-reader, multi-case study datasets previously used for different research purposes in seven countries were collected. Each dataset consisted of DM exams acquired with systems from four different vendors, multiple radiologists' assessments per exam, and ground truth verified by histopathological analysis or follow-up, yielding a total of 2652 exams (653 malignant) and interpretations by 101 radiologists (28 296 independent interpretations). An AI system analyzed these exams yielding a level of suspicion of cancer present between 1 and 10. The detection performance between the radiologists and the AI system was compared using a noninferiority null hypothesis at a margin of 0.05. RESULTS The performance of the AI system was statistically noninferior to that of the average of the 101 radiologists. The AI system had a 0.840 (95% confidence interval [CI] = 0.820 to 0.860) area under the ROC curve and the average of the radiologists was 0.814 (95% CI = 0.787 to 0.841) (difference 95% CI = -0.003 to 0.055). The AI system had an AUC higher than 61.4% of the radiologists. CONCLUSIONS The evaluated AI system achieved a cancer detection accuracy comparable to an average breast radiologist in this retrospective setting. Although promising, the performance and impact of such a system in a screening setting needs further investigation.
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MacInnes EG, Duffy SW, Simpson JA, Wallis MG, Turnbull AE, Wilkinson LS, Satchithananda K, Rahim R, Dodwell D, Hogan BV, Blyuss O, Sharma N. Radiological audit of interval breast cancers: Estimation of tumour growth rates. Breast 2020; 51:114-119. [PMID: 32298962 PMCID: PMC7375675 DOI: 10.1016/j.breast.2020.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/11/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION This multicentre, retrospective study aimed to establish correlation between estimated tumour volume doubling times (TVDT) from a series of interval breast cancers with their clinicopathological features. The potential impact of delayed diagnosis on prognosis was also explored. MATERIALS AND METHODS Interval cancers, where screening mammograms demonstrated changes that were retrospectively classified as either uncertain or suspicious, were reviewed from five screening units within the UK NHS Breast Screening Programme (NHSBSP). Data collected included the time interval between screening mammogram and cancer diagnosis, the size of the initial mammographic abnormality and of the subsequent cancer, demographics, mammographic density and tumour biology. We estimated volume doubling times and the estimated change in size and node status, which would have followed if these cancers had been detected at the previous screen. RESULTS 306 interval cancers meeting the inclusion criteria were identified. Average time from screening to diagnosis was 644 days (SD 276 days). 19% were diagnosed in the first twelve months, 42% in the subsequent twelve months and 39% thereafter. Overall average estimated TVDT was 167 days (95% CI 151-186). Significant differences were noted with age (p = 0.01), grade (p < 0.001) and ER status (p < 0.001) with women under 60, grade 3 cancers and ER negative cancers having shorter TVDTs. HER2 positive tumours had shorter doubling times than HER2 negative, but this difference was not statistically significant. It was estimated that diagnosing these cancers at the previous screen would have increased ten-year survival from 82% to 86%. CONCLUSION High grade, ER negativity and younger age were associated with shorter durations of TVDT. The role of HER2 status on interval cancer growth rate requires further assessment. It is likely that the delayed diagnosis of interval cancers confers a 4% reduction in ten-year survival.
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Affiliation(s)
- Emma G MacInnes
- Leeds Teaching Hospital NHS Trust, Beckett Street, Leeds, LS9 7TF, UK.
| | - Stephen W Duffy
- Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Road, London, E1 4NS, UK.
| | - Julie A Simpson
- Leeds Teaching Hospital NHS Trust, Beckett Street, Leeds, LS9 7TF, UK.
| | - Matthew G Wallis
- Cambridge Breast Unit, And NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, 277 Hills Road, Cambridge, CB2 0QQ, UK.
| | - Anne E Turnbull
- University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK.
| | | | | | - Rumana Rahim
- King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - David Dodwell
- University of Oxford, Wellington Square, Oxford, OX1 2JD, UK.
| | - Brian V Hogan
- Leeds Teaching Hospital NHS Trust, Beckett Street, Leeds, LS9 7TF, UK.
| | - Oleg Blyuss
- Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Road, London, E1 4NS, UK.
| | - Nisha Sharma
- Leeds Teaching Hospital NHS Trust, Beckett Street, Leeds, LS9 7TF, UK.
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Bick U, Trimboli RM, Athanasiou A, Balleyguier C, Baltzer PAT, Bernathova M, Borbély K, Brkljacic B, Carbonaro LA, Clauser P, Cassano E, Colin C, Esen G, Evans A, Fallenberg EM, Fuchsjaeger MH, Gilbert FJ, Helbich TH, Heywang-Köbrunner SH, Herranz M, Kinkel K, Kilburn-Toppin F, Kuhl CK, Lesaru M, Lobbes MBI, Mann RM, Martincich L, Panizza P, Pediconi F, Pijnappel RM, Pinker K, Schiaffino S, Sella T, Thomassin-Naggara I, Tardivon A, Ongeval CV, Wallis MG, Zackrisson S, Forrai G, Herrero JC, Sardanelli F. Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging. Insights Imaging 2020; 11:12. [PMID: 32025985 PMCID: PMC7002629 DOI: 10.1186/s13244-019-0803-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/10/2019] [Indexed: 12/13/2022] Open
Abstract
We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as "high-risk" or B3 lesions). Finally, seven frequently asked questions are answered.
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Affiliation(s)
- Ulrich Bick
- Clinic of Radiology, Charité Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Rubina M Trimboli
- PhD Course in Integrative Biomedical Research, Department of Biomedical Science for Health, Università degli Studi di Milano, Via Mangiagalli, 31, 20133, Milan, Italy
| | - Alexandra Athanasiou
- Breast Imaging Department, MITERA Hospital, 6, Erithrou Stavrou Str. 151 23 Marousi, Athens, Greece
| | - Corinne Balleyguier
- Department of Radiology, Gustave-Roussy Cancer Campus, 114 Rue Edouard Vaillant, 94800, Villejuif, France
| | - Pascal A T Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Wien, Austria
| | - Maria Bernathova
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Wien, Austria
| | | | - Boris Brkljacic
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Luca A Carbonaro
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Paola Clauser
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Wien, Austria
| | - Enrico Cassano
- Breast Imaging Division, European Institute of Oncology, Milan, Italy
| | - Catherine Colin
- Radiology Unit, Hospices Civils de Lyon, Centre Hospitalo-Universitaire Femme Mère Enfant, 59 Boulevard Pinel, 69 677, Bron Cedex, France
| | - Gul Esen
- School of Medicine, Department of Radiology, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Andrew Evans
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Tom McDonald Avenue, Dundee, UK
| | - Eva M Fallenberg
- Diagnostic and Interventional Breast Imaging, Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael H Fuchsjaeger
- Division of General Radiology, Department of Radiology, Medical University Graz, Auenbruggerplatz 9, 8036, Graz, Austria
| | - Fiona J Gilbert
- Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, Hills road, Cambridge, CB2 0QQ, UK
| | - Thomas H Helbich
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Wien, Austria
| | | | - Michel Herranz
- CyclotronUnit, GALARIA-SERGAS, Nuclear Medicine Department and Molecular ImagingGroup, Instituto de Investigación Sanitaria (IDIS), Santiago de Compostela, Spain
| | - Karen Kinkel
- Institut de Radiologie, Clinique des Grangettes, Chemin des Grangettes 7, 1224 Chêne-Bougeries, Genève, Switzerland
| | - Fleur Kilburn-Toppin
- Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, Hills road, Cambridge, CB2 0QQ, UK
| | - Christiane K Kuhl
- University Hospital of Aachen, Rheinisch-Westfälische Technische Hochschule, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Mihai Lesaru
- Radiology and Imaging Laboratory, Fundeni Institute, Bucharest, Romania
| | - Marc B I Lobbes
- Department of Radiology, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, PO Box 5500, 6130 MB, Sittard-Geleen, The Netherlands
| | - Ritse M Mann
- Department of Radiology, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Laura Martincich
- Unit of Radiodiagnostics ASL AT, Via Conte Verde 125, 14100, Asti, Italy
| | - Pietro Panizza
- Breast Imaging Unit, Scientific Institute (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| | - Federica Pediconi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Ruud M Pijnappel
- Department of Imaging, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Katja Pinker
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Wien, Austria.,Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Simone Schiaffino
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Tamar Sella
- Department of Diagnostic Imaging, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Isabelle Thomassin-Naggara
- Department of Radiology, Sorbonne Université, APHP, Hôpital Tenon, 4, rue de la Chine, 75020, Paris, France
| | - Anne Tardivon
- Department of Radiology, Institut Curie, Paris, France
| | - Chantal Van Ongeval
- Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Biomedical Research Unit, Box 97, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Sophia Zackrisson
- Diagnostic Radiology, Department of Translational Medicine, Faculty of Medicine, Lund University, Skåne University Hospital Malmö, SE-205 02, Malmö, Sweden
| | - Gabor Forrai
- Department of Radiology, Duna Medical Center, Budapest, Hungary
| | | | - Francesco Sardanelli
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy. .,Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy.
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Blanks RG, Given-Wilson RM, Cohen SL, Patnick J, Alison RJ, Wallis MG. Correction to: An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme. Eur Radiol 2019; 29:7074-7075. [PMID: 31278572 DOI: 10.1007/s00330-019-06307-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The original version of this article, published on 04 February 2019, unfortunately contained a mistake.
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Affiliation(s)
- R G Blanks
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Oxford, UK.
| | - R M Given-Wilson
- Department of Radiology, St Georges University Hospital Foundation Trust, London, UK
| | | | - J Patnick
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - R J Alison
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - M G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
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Blanks RG, Given-Wilson RM, Cohen SL, Patnick J, Alison RJ, Wallis MG. An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme. Eur Radiol 2019; 29:3812-3819. [PMID: 30715589 DOI: 10.1007/s00330-018-5957-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/12/2018] [Accepted: 12/05/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To develop methods to model the relationship between cancer detection and recall rates to inform professional standards. METHODS Annual screening programme information for each of the 80 English NHSBSP units (totalling 11.3 million screening tests) for the seven screening years from 1 April 2009 to 31 March 2016 and some Dutch screening programme information were used to produce linear and non-linear models. The non-linear models estimated the modelled maximum values (MMV) for cancers detected at different grades and estimated how rapidly the MMV was reached (the modelled 'slope' (MS)). Main outcomes include the detection rate for combined invasive/micro-invasive and high-grade DCIS (IHG) detection rate and the low/intermediate grade DCIS (LIG) detection rate. RESULTS At prevalent screens for IHG cancers, 99% of the MMV was reached at a recall rate of 7.0%. The LIG detection rate had no discernible plateau, increasing linearly at a rate of 0.12 per 1000 for every 1% increase in recall rate. At incident screens, 99% of the MMV for IHG cancer detection was 4.0%. LIG DCIS increased linearly at a rate of 0.18 per 1000 per 1% increase in recall rate. CONCLUSIONS Our models demonstrate the diminishing returns associated with increasing recall rates. The screening programme in England could use the models to set recall rate ranges, and other countries could explore similar methodology. KEY POINTS • Question: How can we determine optimum recall rates in breast cancer screening? • Findings: In this large observational study, we show that increases in recall rates above defined levels are almost exclusively associated with false positive recalls and a very small increase in low/intermediate grade DCIS. • Meaning: High recall rates are not associated with increases in detection of life-threatening cancers. The models developed in this paper can be used to help set recall rate ranges that maximise benefit and minimise harm.
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Affiliation(s)
- R G Blanks
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Oxford, UK.
| | - R M Given-Wilson
- Department of Radiology, St Georges University Hospital Foundation Trust, London, UK
| | | | - J Patnick
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - R J Alison
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - M G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
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Blanks RG, Given-Wilson R, Alison R, Jenkins J, Wallis MG. An analysis of 11.3 million screening tests examining the association between needle biopsy rates and cancer detection rates in the English NHS Breast Cancer Screening Programme. Clin Radiol 2019; 74:384-389. [PMID: 30799096 DOI: 10.1016/j.crad.2019.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/23/2019] [Indexed: 11/24/2022]
Abstract
AIM To examine the association between recall, needle biopsy, and cancer detection rates to inform the setting of target ranges to optimise the benefit to harm ratio of breast screening programmes. MATERIALS AND METHODS Annual screening programme information from 2009/10 to 2015/16 for the 80 screening units of the English National Health Service Breast Screening Programme (totalling 11.3 million screening tests) was obtained from annual (KC62) returns. Linear regression models were used to examine the association between needle biopsy rates and recall rates and non-linear regression models to examine the association between cancer detection rates and needle biopsy rates. RESULTS The models show and quantify the diminishing returns for prevalent screens with increasing biopsy rates. A biopsy rate increase from 10 to 20 per 1,000 increases the cancer detection rate by 2.13 per 1,000 with four extra biopsies per extra cancer detected. Increasing the biopsy rate from 40 to 50 per 1,000, increases the cancer detection rate by only 0.25 per 1,000, with 40 extra biopsies per extra cancer detected. Although diminishing returns are also seen at incident screens, screening is generally more efficient. CONCLUSIONS Increasing needle biopsy rates leads to rapidly diminishing returns in cancer detection and a marked increase in non-malignant/benign needle biopsies. Much of the harms associated with screening in terms of false-positive recall rates and non-cancer biopsies occur at prevalent screens with much lower rates at incident screens. Needle biopsy rate targets should be considered together with recall rate targets to maximise benefit and minimise harm.
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Affiliation(s)
- R G Blanks
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford, OX3 7LF, UK.
| | - R Given-Wilson
- Department of Radiology, St Georges University Hospital Foundation Trust, UK
| | - R Alison
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford, OX3 7LF, UK
| | - J Jenkins
- Breast Screening Programme, Public Health England, London, UK
| | - M G Wallis
- Cambridge Breast Unit, NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, UK
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Blanks RG, Wallis MG, Alison R, Kearins O, Jenkins J, Patnick J, Given-Wilson RM. Impact of Digital Mammography on Cancer Detection and Recall Rates: 11.3 Million Screening Episodes in the English National Health Service Breast Cancer Screening Program. Radiology 2019; 290:629-637. [PMID: 30526360 DOI: 10.1148/radiol.2018181426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To report the impact of changing from screen-film mammography to digital mammography (DM) in a large organized national screening program. Materials and Methods A retrospective analysis of prospectively collected annual screening data from 2009-2010 to 2015-2016 for the 80 facilities of the English National Health Service Breast Cancer Screening Program, together with estimates of DM usage for three time periods, enabled the effect of DM to be measured in a study of 11.3 million screening episodes in women aged 45-70 years (mean age, 59 years). Regression models were used to estimate percentage and absolute change in detection rates due to DM. Results The overall cancer detection rate was 14% greater with DM (P < .001). There were higher rates of detection of grade 1 and 2 invasive cancers (both ductal and lobular), but no change in the detection of grade 3 invasive cancers. The recall rate was almost unchanged by the introduction of DM. At prevalent (first) screening episodes for women aged 45-52 years, DM increased the overall detection rate by 19% (P < .001) and for incident screening episodes in women aged 53-70 years by 13% (P < .001). Conclusion The overall cancer detection rate was 14% greater with digital mammography with no change in recall rates and without confounding by changes in other factors. There was a substantially higher detection of grade 1 and grade 2 invasive cancers, including both ductal and lobular cancers, but no change in the detection of grade 3 invasive cancers. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by C.I. Lee and J.M. Lee in this issue.
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Affiliation(s)
- Roger G Blanks
- From the Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, England (R.G.B., J.P., R.A.); Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, England (M.G.W.); Screening QA Service, Public Health England, London, England (O.K.); Breast Screening Programme, Public Health England, London, England (J.J.); and Department of Radiology, St George's University Hospital Foundation Trust, London, England (R.M.G.W.)
| | - Matthew G Wallis
- From the Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, England (R.G.B., J.P., R.A.); Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, England (M.G.W.); Screening QA Service, Public Health England, London, England (O.K.); Breast Screening Programme, Public Health England, London, England (J.J.); and Department of Radiology, St George's University Hospital Foundation Trust, London, England (R.M.G.W.)
| | - Rupert Alison
- From the Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, England (R.G.B., J.P., R.A.); Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, England (M.G.W.); Screening QA Service, Public Health England, London, England (O.K.); Breast Screening Programme, Public Health England, London, England (J.J.); and Department of Radiology, St George's University Hospital Foundation Trust, London, England (R.M.G.W.)
| | - Olive Kearins
- From the Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, England (R.G.B., J.P., R.A.); Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, England (M.G.W.); Screening QA Service, Public Health England, London, England (O.K.); Breast Screening Programme, Public Health England, London, England (J.J.); and Department of Radiology, St George's University Hospital Foundation Trust, London, England (R.M.G.W.)
| | - Jacquie Jenkins
- From the Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, England (R.G.B., J.P., R.A.); Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, England (M.G.W.); Screening QA Service, Public Health England, London, England (O.K.); Breast Screening Programme, Public Health England, London, England (J.J.); and Department of Radiology, St George's University Hospital Foundation Trust, London, England (R.M.G.W.)
| | - Julietta Patnick
- From the Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, England (R.G.B., J.P., R.A.); Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, England (M.G.W.); Screening QA Service, Public Health England, London, England (O.K.); Breast Screening Programme, Public Health England, London, England (J.J.); and Department of Radiology, St George's University Hospital Foundation Trust, London, England (R.M.G.W.)
| | - Rosalind M Given-Wilson
- From the Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, England (R.G.B., J.P., R.A.); Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, England (M.G.W.); Screening QA Service, Public Health England, London, England (O.K.); Breast Screening Programme, Public Health England, London, England (J.J.); and Department of Radiology, St George's University Hospital Foundation Trust, London, England (R.M.G.W.)
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Fredenberg E, Willsher P, Moa E, Dance DR, Young KC, Wallis MG. Measurement of breast-tissue x-ray attenuation by spectral imaging: fresh and fixed normal and malignant tissue. Phys Med Biol 2018; 63:235003. [PMID: 30465547 DOI: 10.1088/1361-6560/aaea83] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Knowledge of x-ray attenuation is essential for developing and evaluating x-ray imaging technologies. In mammography, measurement of breast density, dose estimation, and differentiation between cysts and solid tumours are example applications requiring accurate data on tissue attenuation. Published attenuation data are, however, sparse and cover a relatively wide range. To supplement available data we have previously measured the attenuation of cyst fluid and solid lesions using photon-counting spectral mammography. The present study aims to measure the attenuation of normal adipose and glandular tissue, and to measure the effect of formalin fixation, a major uncertainty in published data. A total of 27 tumour specimens, seven fibro-glandular tissue specimens, and 15 adipose tissue specimens were included. Spectral (energy-resolved) images of the samples were acquired and the image signal was mapped to equivalent thicknesses of two known reference materials, from which x-ray attenuation as a function of energy can be derived. The spread in attenuation between samples was relatively large, partly because of natural variation. The variation of malignant and glandular tissue was similar, whereas that of adipose tissue was lower. Formalin fixation slightly altered the attenuation of malignant and glandular tissue, whereas the attenuation of adipose tissue was not significantly affected. The difference in attenuation between fresh tumour tissue and cyst fluid was smaller than has previously been measured for fixed tissue, but the difference was still significant and discrimination of these two tissue types is still possible. The difference between glandular and malignant tissue was close-to significant; it is reasonable to expect a significant difference with a larger set of samples. We believe that our studies have contributed to lower the overall uncertainty of breast tissue attenuation in the literature due to the relatively large sample sets, the novel measurement method, and by clarifying the difference between fresh and fixed tissue.
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Affiliation(s)
- Erik Fredenberg
- Philips Research, Knarrarnäsgatan 7, 164 85 Kista, Sweden. Philips Health Systems, Mammography Solutions, Torshamnsgatan 30A, 164 40 Kista, Sweden. Author to whom any correspondence should be addressed
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Berggren K, Eriksson M, Hall P, Wallis MG, Fredenberg E. In vivo measurement of the effective atomic number of breast skin using spectral mammography. ACTA ACUST UNITED AC 2018; 63:215023. [DOI: 10.1088/1361-6560/aae78c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Thompson AM, Clements K, Cheung S, Pinder SE, Lawrence G, Sawyer E, Kearins O, Ball GR, Tomlinson I, Hanby A, Thomas JSJ, Maxwell AJ, Wallis MG, Dodwell DJ. Management and 5-year outcomes in 9938 women with screen-detected ductal carcinoma in situ: the UK Sloane Project. Eur J Cancer 2018; 101:210-219. [PMID: 30092498 DOI: 10.1016/j.ejca.2018.06.027] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/13/2018] [Accepted: 06/19/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management of screen-detected ductal carcinoma in situ (DCIS) remains controversial. METHODS A prospective cohort of patients with DCIS diagnosed through the UK National Health Service Breast Screening Programme (1st April 2003 to 31st March 2012) was linked to national databases and case note review to analyse patterns of care, recurrence and mortality. RESULTS Screen-detected DCIS in 9938 women, with mean age of 60 years (range 46-87), was treated by mastectomy (2931) or breast conserving surgery (BCS) (7007; 70%). At 64 months median follow-up, 697 (6.8%) had further DCIS or invasive breast cancer after BCS (7.8%) or mastectomy (4.5%) (p < 0.001). Breast radiotherapy (RT) after BCS (4363/7007; 62.3%) was associated with a 3.1% absolute reduction in ipsilateral recurrent DCIS or invasive breast cancer (no RT: 7.2% versus RT: 4.1% [p < 0.001]) and a 1.9% absolute reduction for ipsilateral invasive breast recurrence (no RT: 3.8% versus RT: 1.9% [p < 0.001]), independent of the excision margin width or size of DCIS. Women without RT after BCS had more ipsilateral breast recurrences (p < 0.001) when the radial excision margin was <2 mm. Adjuvant endocrine therapy (1208/9938; 12%) was associated with a reduction in any ipsilateral recurrence, whether RT was received (hazard ratio [HR] 0.57; 95% confidence interval [CI] 0.41-0.80) or not (HR 0.68; 95% CI 0.51-0.91) after BCS. Women who developed invasive breast recurrence had a worse survival than those with recurrent DCIS (p < 0.001). Among 321 (3.2%) who died, only 46 deaths were attributed to invasive breast cancer. CONCLUSION Recurrent DCIS or invasive cancer is uncommon after screen-detected DCIS. Both RT and endocrine therapy were associated with a reduction in further events but not with breast cancer mortality within 5 years of diagnosis. Further research to identify biomarkers of recurrence risk, particularly as invasive disease, is indicated.
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Affiliation(s)
| | - Karen Clements
- Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Shan Cheung
- Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Sarah E Pinder
- Division of Cancer Studies, King's College London, 9th Floor Innovation Hub, Comprehensive Cancer Centre, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK.
| | - Gill Lawrence
- Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Elinor Sawyer
- Division of Cancer Studies, King's College London, 9th Floor Innovation Hub, Comprehensive Cancer Centre, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK.
| | - Olive Kearins
- Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Graham R Ball
- John van Geest Cancer Research Centre, Nottingham Trent University, Clifton Lane, Nottingham NG11 8NS, UK.
| | - Ian Tomlinson
- Oxford Centre for Cancer Gene Research, Molecular Pathology and Diagnostics Theme, Oxford NIHR Comprehensive Biomedical Research Centre, Wellcome Trust Centre for Human Genetics, Roosevelt Drive, Oxford OX3 7BN, UK.
| | - Andrew Hanby
- Leeds Institute of Cancer and Pathology (LICAP), Section of Pathology and Tumour Biology, Wellcome Trust Brenner Building, Level 4, Room 4.13 St James's University Hospital, Beckett Street, Leeds, LS9 7TF UK.
| | | | - Anthony J Maxwell
- Nightingale Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK; School of Health Sciences, University of Manchester, Manchester, M13 9PT, UK.
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK.
| | - David J Dodwell
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK.
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Abstract
Purpose To investigate the effect of double readings by a second radiologist on recall rates, cancer detection, and characteristics of cancers detected in the National Health Service Breast Screening Program in England. Materials and Methods In this retrospective analysis, 805 206 women were evaluated through screening and diagnostic test results by extracting 1 year of routine data from 33 English breast screening centers. Centers used double reading of digital mammograms, with arbitration if there were discrepant interpretations. Information on reader decisions, with results of follow-up tests, were used to explore the effect of the second reader. The statistical tests used were the test for equality of proportions, the χ2 test for independence, and the t test. Results The first reader recalled 4.76% of women (38 295 of 805 206 women; 95% confidence interval [CI]: 4.71%, 4.80%). Two readers recalled 6.19% of women in total (49 857 of 805 206 women; 95% CI: 6.14%, 6.24%), but arbitration of discordant readings reduced the recall rate to 4.08% (32 863 of 805 206 women; 95% CI: 4.04%, 4.12%; P < .001). A total of 7055 cancers were detected, of which 627 (8.89%; 95% CI: 8.22%, 9.55%; P < .001) were detected by the second reader only. These additional cancers were more likely to be ductal carcinoma in situ (30.5% [183 of 600] vs 22.0% [1344 of 6114]; P < .001), and additional invasive cancers were smaller (mean size, 14.2 vs 16.7 mm; P < .001), had fewer involved nodes, and were likely to be lower grade. Conclusion Double reading with arbitration reduces recall and increases cancer detection compared with single reading. Cancers detected only by the second reader were smaller, of lower grade, and had less nodal involvement. © RSNA, 2018.
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Affiliation(s)
- Sian Taylor-Phillips
- From the Warwick Medical School, University of Warwick, Gibbett Hill
Rd, Coventry CV4 7AL, England (S.T., D.J., C.S., J.D., A.C.); and Cambridge
Breast Unit, Cambridge University Hospitals National Health Service Foundation
Trust, and National Institute for Health Research Cambridge Biomedical Research
Centre, Cambridge, England (M.G.W.)
| | - David Jenkinson
- From the Warwick Medical School, University of Warwick, Gibbett Hill
Rd, Coventry CV4 7AL, England (S.T., D.J., C.S., J.D., A.C.); and Cambridge
Breast Unit, Cambridge University Hospitals National Health Service Foundation
Trust, and National Institute for Health Research Cambridge Biomedical Research
Centre, Cambridge, England (M.G.W.)
| | - Chris Stinton
- From the Warwick Medical School, University of Warwick, Gibbett Hill
Rd, Coventry CV4 7AL, England (S.T., D.J., C.S., J.D., A.C.); and Cambridge
Breast Unit, Cambridge University Hospitals National Health Service Foundation
Trust, and National Institute for Health Research Cambridge Biomedical Research
Centre, Cambridge, England (M.G.W.)
| | - Matthew G. Wallis
- From the Warwick Medical School, University of Warwick, Gibbett Hill
Rd, Coventry CV4 7AL, England (S.T., D.J., C.S., J.D., A.C.); and Cambridge
Breast Unit, Cambridge University Hospitals National Health Service Foundation
Trust, and National Institute for Health Research Cambridge Biomedical Research
Centre, Cambridge, England (M.G.W.)
| | - Janet Dunn
- From the Warwick Medical School, University of Warwick, Gibbett Hill
Rd, Coventry CV4 7AL, England (S.T., D.J., C.S., J.D., A.C.); and Cambridge
Breast Unit, Cambridge University Hospitals National Health Service Foundation
Trust, and National Institute for Health Research Cambridge Biomedical Research
Centre, Cambridge, England (M.G.W.)
| | - Aileen Clarke
- From the Warwick Medical School, University of Warwick, Gibbett Hill
Rd, Coventry CV4 7AL, England (S.T., D.J., C.S., J.D., A.C.); and Cambridge
Breast Unit, Cambridge University Hospitals National Health Service Foundation
Trust, and National Institute for Health Research Cambridge Biomedical Research
Centre, Cambridge, England (M.G.W.)
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Maxwell AJ, Clements K, Hilton B, Dodwell DJ, Evans A, Kearins O, Pinder SE, Thomas J, Wallis MG, Thompson AM. Risk factors for the development of invasive cancer in unresected ductal carcinoma in situ. Eur J Surg Oncol 2018; 44:429-435. [PMID: 29398324 DOI: 10.1016/j.ejso.2017.12.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/04/2017] [Accepted: 12/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The natural history of ductal carcinoma in situ (DCIS) remains uncertain. The risk factors for the development of invasive cancer in unresected DCIS are unclear. METHODS Women diagnosed with DCIS on needle biopsy after 1997 who did not undergo surgical resection for ≥1 year after diagnosis were identified by breast centres and the cancer registry and outcomes were reviewed. RESULTS Eighty-nine women with DCIS diagnosed 1998-2010 were identified. The median age at diagnosis was 75 (range 44-94) years with median follow-up (diagnosis to death, invasive disease or last review) of 59 (12-180) months. Twenty-nine women (33%) developed invasive breast cancer after a median interval of 45 (12-144) months. 14/29 (48%) with high grade, 10/31 (32%) with intermediate grade and 3/17 (18%) with low grade DCIS developed invasive cancer after median intervals of 38, 60 and 51 months. The cumulative incidence of invasion was significantly higher in high grade DCIS than other grades (p = .0016, log-rank test). Invasion was more frequent in lesions with calcification as the predominant feature (23/50 v. 5/25; p = .042) and in younger women (p = .0002). Endocrine therapy was associated with a lower rate of invasive breast cancer (p = .048). CONCLUSIONS High cytonuclear grade, mammographic microcalcification, young age and lack of endocrine therapy were risk factors for DCIS progression to invasive cancer. Surgical excision of high grade DCIS remains the treatment of choice. Given the uncertain long-term natural history of non-high grade DCIS, the option of active surveillance of women with this condition should be offered within a clinical trial.
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Affiliation(s)
- Anthony J Maxwell
- Nightingale Centre, Wythenshawe Hospital, Manchester, M23 9LT, UK; Division of Informatics, Imaging & Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PT, UK.
| | - Karen Clements
- Screening Quality Assurance Service (Midlands and East), Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Bridget Hilton
- Screening Quality Assurance Service (Midlands and East), Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - David J Dodwell
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK.
| | - Andrew Evans
- Ninewells Hospital and Medical School, Mailbox 4, Level 6, Dundee, DD1 9SY, UK.
| | - Olive Kearins
- Screening Quality Assurance Service (Midlands and East), Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Sarah E Pinder
- Cancer Studies, King's College London, 9th Floor, Innovation Hub, Comprehensive Cancer Centre, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK.
| | - Jeremy Thomas
- Department of Pathology, Western General Hospital, Edinburgh, EH4 2XU, UK.
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK.
| | - Alastair M Thompson
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Thompson AM, Clements K, Cheung S, Pinder SE, Lawrence G, Sawyer E, Kearins O, Ball GR, Tomlinson I, Hanby AM, Thomas J, Maxwell AJ, Wallis MG, Dodwell DJ. Abstract P4-15-02: Impact of radiotherapy and endocrine therapy on further events: Final multivariate analysis of a prospective, national cohort study of screen detected ductal carcinoma in situ (DCIS) of the breast. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p4-15-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Key words: DCIS, radiotherapy, endocrine therapy, survival, surgical margins
Background:
The benefits and risks of breast screening remain controversial, with particular concern that ductal carcinoma in situ (DCIS) may be over-diagnosed and over-treated. There is little prospective data on treatment or outcomes for screen detected DCIS.
Methods:
A prospective cohort of non-invasive lesions diagnosed through the United Kingdom National Health Service Breast Screening Programme (NHSBSP) (1 April 2003 to 31 March 2012) was linked to national databases and case note review to analyse patterns of care, recurrence and mortality.
Results:
Screen-detected DCIS in 9938 women was analysed, 33% (9938/30041) of women with a final diagnosis of non-invasive breast neoplasia diagnosed through the NHSBSP over the same time.
The patients (mean age was 60 years: range 46-87 years) were treated by breast conservation surgery (BCS; 7007; 70.5%) or mastectomy (2931). At 64 months median follow up, 697 (6.8%) had further DCIS or invasive breast cancer after BCS (7.8%) or mastectomy (4.5%) (p<0.001) and 228 women (2.3%) developed contralateral malignancy.
Breast radiotherapy (RT) after BCS (4363/7007; 62%) was associated with a 3.1% absolute reduction in any ipsilateral DCIS or invasive cancer (No RT: 7.2% vs RT: 4.1% (p<0.001) and a 1.9% absolute reduction for ipsilateral invasive breast recurrence (No RT: 3.8% vs RT: 1.9% (p<0.001), independent of excision margin width or size of DCIS. Women who did not receive RT after BCS had more ipsilateral events (p=0.008) when the radial excision margin was <2mm. RT was rarely used after mastectomy for DCIS (33 women). Adjuvant endocrine therapy (prescribed for 1208/9938; 12.2%) was associated with a reduction in any ipsilateral recurrence, independent of whether women did (HR 0.57: 95% CI 0.41 - 0.80) or did not (HR 0.68: 95% CI 0.51 - 0.91) receive RT after BCS.
Among 321 (3.2%) women who died, 46 deaths (0.5%; 14.3% of all deaths) were attributed to invasive breast cancer. Death from breast cancer was uncommon and outnumbered 5:1 by death due to other causes. RT after BCS was associated with a non-significant 0.2% absolute reduction in breast cancer mortality. However, women who developed invasive breast cancer had a worse survival than those with further DCIS (p<0.001).
Conclusions:
Recurrent DCIS or invasive cancer is uncommon following screen detected DCIS treated by surgery and adjuvant therapy. Both RT and endocrine therapy following surgery were associated with a significant reduction in further DCIS and invasive disease, but not breast cancer mortality, within 5 years of diagnosis. This study quantifies the benefits of radiotherapy and endocrine therapy to inform decision making in the management of screen detected DCIS.
Citation Format: Thompson AM, Clements K, Cheung S, Pinder SE, Lawrence G, Sawyer E, Kearins O, Ball GR, Tomlinson I, Hanby AM, Thomas J, Maxwell AJ, Wallis MG, Dodwell DJ. Impact of radiotherapy and endocrine therapy on further events: Final multivariate analysis of a prospective, national cohort study of screen detected ductal carcinoma in situ (DCIS) of the breast [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-02.
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Affiliation(s)
- AM Thompson
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - K Clements
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - S Cheung
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - SE Pinder
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - G Lawrence
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - E Sawyer
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - O Kearins
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - GR Ball
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - I Tomlinson
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - AM Hanby
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - J Thomas
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - AJ Maxwell
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - MG Wallis
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - DJ Dodwell
- The University of Texas MD Anderson Cancer Center, Houston, TX; Public Health England; Guy's Hospital; Nottingham Trent University, Nottingham, United Kingdom; Oxford NIHR Comprehensive Biomedical Research Centre, Oxford, United Kingdom; St James Hospital, Leeds, United Kingdom; Western General Hospital, Edinburgh, United Kingdom; University of Manchester, Manchester, United Kingdom; Cambridge University Hospitals, Cambridge, United Kingdom; University of Oxford, Oxford, United Kingdom
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Russell NS, Krul IM, van Eggermond AM, Aleman BM, Cooke R, Kuiper S, Allen SD, Wallis MG, Llanas D, Diallo I, de Vathaire F, Smith SA, Hauptmann M, Broeks A, Swerdlow AJ, Van Leeuwen FE. Retrospective methods to estimate radiation dose at the site of breast cancer development after Hodgkin lymphoma radiotherapy. Clin Transl Radiat Oncol 2017; 7:20-27. [PMID: 29594225 PMCID: PMC5862668 DOI: 10.1016/j.ctro.2017.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 09/16/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND An increased risk of breast cancer following radiotherapy for Hodgkin lymphoma (HL) has now been robustly established. In order to estimate the dose-response relationship more accurately, and to aid clinical decision making, a retrospective estimation of the radiation dose delivered to the site of the subsequent breast cancer is required. METHODS For 174 Dutch and 170 UK female patients with breast cancer following HL treatment, the 3-dimensional position of the breast cancer in the affected breast was determined and transferred onto a CT-based anthropomorphic phantom. Using a radiotherapy treatment planning system the dose distribution on the CT-based phantom was calculated for the 46 different radiation treatment field set-ups used in the study population. The estimated dose at the centre of the breast cancer, and a margin to reflect dose uncertainty were determined on the basis of the location of the tumour and the isodose lines from the treatment planning. We assessed inter-observer variation and for 47 patients we compared the results with a previously applied dosimetry method. RESULTS The estimated median point dose at the centre of the breast cancer location was 29.75 Gy (IQR 5.8-37.2), or about 75% of the prescribed radiotherapy dose. The median dose uncertainty range was 5.97 Gy. We observed an excellent inter-observer variation (ICC 0.89 (95% CI: 0.74-0.95)). The absolute agreement intra-class correlation coefficient (ICC) for inter-method variation was 0.59 (95% CI: 0.37-0.75), indicating (nearly) good agreement. There were no systematic differences in the dose estimates between observers or methods. CONCLUSION Estimates of the dose at the point of a subsequent breast cancer show good correlation between methods, but the retrospective nature of the estimates means that there is always some uncertainty to be accounted for.
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Affiliation(s)
- Nicola S. Russell
- Department of Radiation Oncology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Inge M. Krul
- Divison of Psychosocial Research, Epidemiology and Biostatistics, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Anna M. van Eggermond
- Divison of Psychosocial Research, Epidemiology and Biostatistics, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Berthe M.P. Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Rosie Cooke
- Division of Genetics and Epidemiology (R.C., A.J.S.), Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK
| | - Susanne Kuiper
- Department of Radiation Oncology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Steven D. Allen
- Department of Radiology, Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, Surrey SM2 5PT, UK
| | - Matthew G. Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, England, UK
| | - Damien Llanas
- Cancer and Radiation Team, Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale Unit 1018, Villejuif, France
| | - Ibrahima Diallo
- Cancer and Radiation Team, Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale Unit 1018, Villejuif, France
| | - Florent de Vathaire
- Cancer and Radiation Team, Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale Unit 1018, Villejuif, France
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, TX, United States
| | - Michael Hauptmann
- Divison of Psychosocial Research, Epidemiology and Biostatistics, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Annegien Broeks
- Division of Molecular Pathology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Anthony J. Swerdlow
- Division of Genetics and Epidemiology (R.C., A.J.S.), Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK
- Division of Breast Cancer Research (A.J.S.), Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK
| | - Flora E. Van Leeuwen
- Divison of Psychosocial Research, Epidemiology and Biostatistics, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
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Warren LM, Halling-Brown MD, Looney PT, Dance DR, Wallis MG, Given-Wilson RM, Wilkinson L, McAvinchey R, Young KC. Image processing can cause some malignant soft-tissue lesions to be missed in digital mammography images. Clin Radiol 2017; 72:799.e1-799.e8. [PMID: 28457521 DOI: 10.1016/j.crad.2017.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/24/2017] [Accepted: 03/23/2017] [Indexed: 11/19/2022]
Abstract
AIM To investigate the effect of image processing on cancer detection in mammography. METHODS AND MATERIALS An observer study was performed using 349 digital mammography images of women with normal breasts, calcification clusters, or soft-tissue lesions including 191 subtle cancers. Images underwent two types of processing: FlavourA (standard) and FlavourB (added enhancement). Six observers located features in the breast they suspected to be cancerous (4,188 observations). Data were analysed using jackknife alternative free-response receiver operating characteristic (JAFROC) analysis. Characteristics of the cancers detected with each image processing type were investigated. RESULTS For calcifications, the JAFROC figure of merit (FOM) was equal to 0.86 for both types of image processing. For soft-tissue lesions, the JAFROC FOM were better for FlavourA (0.81) than FlavourB (0.78); this difference was significant (p=0.001). Using FlavourA a greater number of cancers of all grades and sizes were detected than with FlavourB. FlavourA improved soft-tissue lesion detection in denser breasts (p=0.04 when volumetric density was over 7.5%) CONCLUSIONS: The detection of malignant soft-tissue lesions (which were primarily invasive) was significantly better with FlavourA than FlavourB image processing. This is despite FlavourB having a higher contrast appearance often preferred by radiologists. It is important that clinical choice of image processing is based on objective measures.
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Affiliation(s)
- L M Warren
- National Co-ordinating Centre for the Physics of Mammography, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX, UK.
| | - M D Halling-Brown
- Scientific Computing, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX, UK
| | - P T Looney
- National Co-ordinating Centre for the Physics of Mammography, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX, UK
| | - D R Dance
- National Co-ordinating Centre for the Physics of Mammography, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX, UK; Department of Physics, University of Surrey, Guildford, Surrey, GU2 7JP, UK
| | - M G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK; NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK
| | - R M Given-Wilson
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Tooting, London, SW17 0QT, UK
| | - L Wilkinson
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Tooting, London, SW17 0QT, UK
| | - R McAvinchey
- Jarvis Breast Screening and Diagnostic Centre, Guildford, GU1 1LJ, UK
| | - K C Young
- National Co-ordinating Centre for the Physics of Mammography, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX, UK; Department of Physics, University of Surrey, Guildford, Surrey, GU2 7JP, UK
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Elangovan P, Mackenzie A, Dance DR, Young KC, Cooke V, Wilkinson L, Given-Wilson RM, Wallis MG, Wells K. Design and validation of realistic breast models for use in multiple alternative forced choice virtual clinical trials. Phys Med Biol 2017; 62:2778-2794. [PMID: 28291738 DOI: 10.1088/1361-6560/aa622c] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A novel method has been developed for generating quasi-realistic voxel phantoms which simulate the compressed breast in mammography and digital breast tomosynthesis (DBT). The models are suitable for use in virtual clinical trials requiring realistic anatomy which use the multiple alternative forced choice (AFC) paradigm and patches from the complete breast image. The breast models are produced by extracting features of breast tissue components from DBT clinical images including skin, adipose and fibro-glandular tissue, blood vessels and Cooper's ligaments. A range of different breast models can then be generated by combining these components. Visual realism was validated using a receiver operating characteristic (ROC) study of patches from simulated images calculated using the breast models and from real patient images. Quantitative analysis was undertaken using fractal dimension and power spectrum analysis. The average areas under the ROC curves for 2D and DBT images were 0.51 ± 0.06 and 0.54 ± 0.09 demonstrating that simulated and real images were statistically indistinguishable by expert breast readers (7 observers); errors represented as one standard error of the mean. The average fractal dimensions (2D, DBT) for real and simulated images were (2.72 ± 0.01, 2.75 ± 0.01) and (2.77 ± 0.03, 2.82 ± 0.04) respectively; errors represented as one standard error of the mean. Excellent agreement was found between power spectrum curves of real and simulated images, with average β values (2D, DBT) of (3.10 ± 0.17, 3.21 ± 0.11) and (3.01 ± 0.32, 3.19 ± 0.07) respectively; errors represented as one standard error of the mean. These results demonstrate that radiological images of these breast models realistically represent the complexity of real breast structures and can be used to simulate patches from mammograms and DBT images that are indistinguishable from patches from the corresponding real breast images. The method can generate about 500 radiological patches (~30 mm × 30 mm) per day for AFC experiments on a single workstation. This is the first study to quantitatively validate the realism of simulated radiological breast images using direct blinded comparison with real data via the ROC paradigm with expert breast readers.
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Affiliation(s)
- Premkumar Elangovan
- Medical Imaging Group, Centre for Vision, Speech, and Signal Processing, University of Surrey, Guildford, GU2 7XH, United Kingdom. National Coordination Centre for the Physics of Mammography (NCCPM), Royal Surrey County Hospital, Guildford, GU2 7XX, United Kingdom
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Blanks RG, Moss SM, Wallis MG. Monitoring and evaluating the UK National Health Service Breast Screening Programme: evaluating the variation in radiological performance between individual programmes using PPV-referral diagrams. J Med Screen 2016; 8:24-8. [PMID: 11373846 DOI: 10.1136/jms.8.1.24] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A high quality breast cancer screening programme can be defined as one offering both a high cancer detection rate and a low referral rate of women for further investigation. Such a programme will have as few women as possible undergoing further investigations who do not have a final diagnosis of breast cancer—that is, a high positive predictive value of referral for further investigation. This paper introduces a graphical technique to illustrate individual programme performance. The graph plots positive predictive value of referral against referral rate, with the cancer detection rate expressed as “isobars” on the graph. Confidence limits can be expressed as “boxes” on the diagram. The graph not only illustrates programme performance but also enables suggestions to be made to improve performance. The definition of high quality screening is seen to have a subjective element as well as an objective element, as radiologists have to balance screening sensitivity with specificity. The technique is illustrated using data from the individual screening programmes in the UK National Health Service Breast Screening Programme for the screening year 1 April 1998 to 31 March 1999. The methodology could also be applied to other national screening programmes.
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Affiliation(s)
- R G Blanks
- Cancer Screening Evaluation Unit, Institute of Cancer Research, Section of Epidemiology, D Block, Cotswold Road, Sutton, Surrey SM2 5QF, UK.
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Taylor-Phillips S, Wallis MG, Jenkinson D, Adekanmbi V, Parsons H, Dunn J, Stallard N, Szczepura A, Gates S, Kearins O, Duncan A, Hudson S, Clarke A. Effect of Using the Same vs Different Order for Second Readings of Screening Mammograms on Rates of Breast Cancer Detection: A Randomized Clinical Trial. JAMA 2016; 315:1956-65. [PMID: 27163985 DOI: 10.1001/jama.2016.5257] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Interpreting screening mammograms is a difficult repetitive task that can result in missed cancers and false-positive recalls. In the United Kingdom, 2 film readers independently evaluate each mammogram to search for signs of cancer and examine digital mammograms in batches. However, a vigilance decrement (reduced detection rate with time on task) has been observed in similar settings. OBJECTIVE To determine the effect of changing the order for the second film reader of batches of screening mammograms on rates of breast cancer detection. DESIGN, SETTING, AND PARTICIPANTS A multicenter, double-blind, cluster randomized clinical trial conducted at 46 specialized breast screening centers from the National Health Service Breast Screening Program in England for 1 year (all between December 20, 2012, and November 3, 2014). Three hundred sixty readers participated (mean, 7.8 readers per center)-186 radiologists, 143 radiography advanced practitioners, and 31 breast clinicians, all fully qualified to report mammograms in the NHS breast screening program. INTERVENTIONS The 2 readers examined each batch of digital mammograms in the same order in the control group and in the opposite order to one another in the intervention group. MAIN OUTCOMES AND MEASURES The primary outcome was cancer detection rate; secondary outcomes were rates of recall and disagreements between readers. RESULTS Among 1,194,147 women (mean age, 59.3; SD, 7.49) who had screening mammograms (596,642 in the intervention group; 597,505 in the control group), the images were interpreted in 37,688 batches (median batch size, 35; interquartile range [IQR]; 16-46), with each reader interpreting a median of 176 batches (IQR, 96-278). After completion of all subsequent diagnostic tests, a total of 10,484 cases (0.88%) of breast cancer were detected. There was no significant difference in cancer detection rate with 5272 cancers (0.88%) detected in the intervention group vs 5212 cancers (0.87%) detected in the control group (difference, 0.01% points; 95% CI, -0.02% to 0.04% points; recall rate, 24,681 [4.14%] vs 24,894 [4.17%]; difference, -0.03% points; 95% CI, -0.10% to 0.04% points; or rate of reader disagreements, 20,471 [3.43%] vs 20,793 [3.48%]; difference, -0.05% points; 95% CI, -0.11% to 0.02% points). CONCLUSIONS AND RELEVANCE Interpretation of batches of mammograms by qualified screening mammography readers using a different order vs the same order for the second reading resulted in no significant difference in rates of detection of breast cancer. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN46603370.
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Affiliation(s)
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge Universities NHS Foundation Trust and NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - David Jenkinson
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
| | - Victor Adekanmbi
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
| | - Helen Parsons
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
| | - Janet Dunn
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
| | - Nigel Stallard
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
| | - Ala Szczepura
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
| | - Simon Gates
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
| | - Olive Kearins
- Screening QA Service (Midland & East), Seaton House, City Link, Nottingham, United Kingdom
| | - Alison Duncan
- Warwickshire, Solihull and Coventry Breast Screening Service, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - Sue Hudson
- Peel & Schriek Consulting Limited, London, United Kingdom
| | - Aileen Clarke
- Warwick Medical School, the University of Warwick, Coventry, United Kingdom
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Erhard K, Kilburn-Toppin F, Willsher P, Moa E, Fredenberg E, Wieberneit N, Buelow T, Wallis MG. Characterization of Cystic Lesions by Spectral Mammography: Results of a Clinical Pilot Study. Invest Radiol 2016; 51:340-7. [PMID: 26741891 DOI: 10.1097/rli.0000000000000246] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Round lesions are a common mammographic finding, which can contribute more than 20% of overall recalls at screening. Discrimination of cystic fluid from solid tissue by spectral x-ray imaging has been demonstrated in specimen experiments. This work translates these results into a clinical pilot study to investigate the feasibility of discriminating cystic from solid lesions using spectral mammography. MATERIALS AND METHODS Women undergoing mammography as part of their routine diagnostic workup were consented for analysis of spectral information obtained from a photon-counting mammography system. Images were analyzed retrospectively after diagnosis was confirmed with ultrasound and pathology. Well-defined solitary lesions were delineated independently by 3 expert radiologists. A breast lesion model is generated from the spectral mammography data using the energy-dependent x-ray attenuation of cyst fluid, carcinoma, and adipose and glandular tissue. From the breast lesion model, 2 spectral features are computed and combined in a 2-feature discrimination algorithm, which is evaluated in an analysis of the receiver operating characteristic curve for the task of identifying solid lesions ("positive result"). Expected outcomes on a screening population are extrapolated from this pilot study by cross-validation with bootstrapping using a 95% confidence interval (CI). RESULTS The 2-feature discrimination algorithm was evaluated on the set of 119 eligible lesions (62 solids, 57 cysts) of diameter greater than 10 mm. The area under the receiver operating characteristic curve (AUC) was 0.88 with a specificity of 61% at the 99% sensitivity level on average over all expert radiologists. Cross-validation with bootstrapping of the clinical data revealed an AUC of 0.89 (95% CI, 0.79-0.96) and a specificity of 56% (95% CI, 33%-78%) when operating the algorithm at the 99% sensitivity level. CONCLUSIONS Discriminating cystic from solid lesions with spectral mammography demonstrates promising results with the potential to reduce mammographic recalls. It is estimated that for each missed cancer at least 625 cystic lesions would have been correctly identified and hence would not have been needed to be recalled. Our results justify undertaking a larger reader study to refine the algorithm and determine clinically relevant thresholds to allow safe classification of cystic lesions by spectral mammography.
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Affiliation(s)
- Klaus Erhard
- From the *Philips Research Laboratories, Hamburg, Germany; †Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, United Kingdom; ‡Philips Health Systems, Mammography Solutions, Solna, Sweden; §Philips Medical Systems DMC GmbH, Hamburg, Germany; and ∥NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, United Kingdom
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Fredenberg E, Kilburn-Toppin F, Willsher P, Moa E, Danielsson M, Dance DR, Young KC, Wallis MG. Measurement of breast-tissue x-ray attenuation by spectral mammography: solid lesions. Phys Med Biol 2016; 61:2595-612. [PMID: 26961507 DOI: 10.1088/0031-9155/61/7/2595] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Knowledge of x-ray attenuation is essential for developing and evaluating x-ray imaging technologies. For instance, techniques to distinguish between cysts and solid tumours at mammography screening would be highly desirable to reduce recalls, but the development requires knowledge of the x-ray attenuation for cysts and tumours. We have previously measured the attenuation of cyst fluid using photon-counting spectral mammography. Data on x-ray attenuation for solid breast lesions are available in the literature, but cover a relatively wide range, likely caused by natural spread between samples, random measurement errors, and different experimental conditions. In this study, we have adapted a previously developed spectral method to measure the linear attenuation of solid breast lesions. A total of 56 malignant and 5 benign lesions were included in the study. The samples were placed in a holder that allowed for thickness measurement. Spectral (energy-resolved) images of the samples were acquired and the image signal was mapped to equivalent thicknesses of two known reference materials, which can be used to derive the x-ray attenuation as a function of energy. The spread in equivalent material thicknesses was relatively large between samples, which is likely to be caused mainly by natural variation and only to a minor extent by random measurement errors and sample inhomogeneity. No significant difference in attenuation was found between benign and malignant solid lesions. The separation between cyst-fluid and tumour attenuation was, however, significant, which suggests it may be possible to distinguish cystic from solid breast lesions, and the results lay the groundwork for a clinical trial. In addition, the study adds a relatively large sample set to the published data and may contribute to a reduction in the overall uncertainty in the literature.
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Affiliation(s)
- Erik Fredenberg
- Philips Health Systems, Mammography Solutions, Smidesvägen 5, 171 41 Solna, Sweden
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Mackenzie A, Warren LM, Wallis MG, Given-Wilson RM, Cooke J, Dance DR, Chakraborty DP, Halling-Brown MD, Looney PT, Young KC. The relationship between cancer detection in mammography and image quality measurements. Phys Med 2016; 32:568-74. [PMID: 27061872 PMCID: PMC4856544 DOI: 10.1016/j.ejmp.2016.03.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/19/2016] [Accepted: 03/03/2016] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To investigate the relationship between image quality measurements and the clinical performance of digital mammographic systems. METHODS Mammograms containing subtle malignant non-calcification lesions and simulated malignant calcification clusters were adapted to appear as if acquired by four types of detector. Observers searched for suspicious lesions and gave these a malignancy score. Analysis was undertaken using jackknife alternative free-response receiver operating characteristics weighted figure of merit (FoM). Images of a CDMAM contrast-detail phantom were adapted to appear as if acquired using the same four detectors as the clinical images. The resultant threshold gold thicknesses were compared to the FoMs using a linear regression model and an F-test was used to find if the gradient of the relationship was significantly non-zero. RESULTS The detectors with the best image quality measurement also had the highest FoM values. The gradient of the inverse relationship between FoMs and threshold gold thickness for the 0.25mm diameter disk was significantly different from zero for calcification clusters (p=0.027), but not for non-calcification lesions (p=0.11). Systems performing just above the minimum image quality level set in the European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis resulted in reduced cancer detection rates compared to systems performing at the achievable level. CONCLUSIONS The clinical effectiveness of mammography for the task of detecting calcification clusters was found to be linked to image quality assessment using the CDMAM phantom. The European Guidelines should be reviewed as the current minimum image quality standards may be too low.
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Affiliation(s)
- Alistair Mackenzie
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford GU2 7XX, UK.
| | - Lucy M Warren
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford GU2 7XX, UK.
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, UK.
| | | | - Julie Cooke
- Jarvis Breast Screening and Diagnostic Centre, Guildford, UK.
| | - David R Dance
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford GU2 7XX, UK; Department of Physics, University of Surrey, Guildford GU2 7XH, UK.
| | - Dev P Chakraborty
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Mark D Halling-Brown
- Scientific Computing, Department of Medical Physics, Royal Surrey County Hospital, Guildford, UK.
| | - Padraig T Looney
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford GU2 7XX, UK.
| | - Kenneth C Young
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford GU2 7XX, UK; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, UK.
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Mackenzie A, Warren LM, Wallis MG, Cooke J, Given-Wilson RM, Dance DR, Chakraborty DP, Halling-Brown MD, Looney PT, Young KC. Breast cancer detection rates using four different types of mammography detectors. Eur Radiol 2016; 26:874-83. [PMID: 26105023 PMCID: PMC4691226 DOI: 10.1007/s00330-015-3885-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/26/2015] [Accepted: 06/09/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the performance of different types of detectors in breast cancer detection. METHODS A mammography image set containing subtle malignant non-calcification lesions, biopsy-proven benign lesions, simulated malignant calcification clusters and normals was acquired using amorphous-selenium (a-Se) detectors. The images were adapted to simulate four types of detectors at the same radiation dose: digital radiography (DR) detectors with a-Se and caesium iodide (CsI) convertors, and computed radiography (CR) detectors with a powder phosphor (PIP) and a needle phosphor (NIP). Seven observers marked suspicious and benign lesions. Analysis was undertaken using jackknife alternative free-response receiver operating characteristics weighted figure of merit (FoM). The cancer detection fraction (CDF) was estimated for a representative image set from screening. RESULTS No significant differences in the FoMs between the DR detectors were measured. For calcification clusters and non-calcification lesions, both CR detectors' FoMs were significantly lower than for DR detectors. The calcification cluster's FoM for CR NIP was significantly better than for CR PIP. The estimated CDFs with CR PIP and CR NIP detectors were up to 15% and 22% lower, respectively, than for DR detectors. CONCLUSION Cancer detection is affected by detector type, and the use of CR in mammography should be reconsidered. KEY POINTS The type of mammography detector can affect the cancer detection rates. CR detectors performed worse than DR detectors in mammography. Needle phosphor CR performed better than powder phosphor CR. Calcification clusters detection is more sensitive to detector type than other cancers.
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Affiliation(s)
- Alistair Mackenzie
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford, GU2 7XX, UK.
- Department of Physics, University of Surrey, Guildford, GU2 7XH, UK.
| | - Lucy M Warren
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford, GU2 7XX, UK
- Department of Physics, University of Surrey, Guildford, GU2 7XH, UK
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Julie Cooke
- Jarvis Breast Screening and Diagnostic Centre, Guildford, UK
| | | | - David R Dance
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford, GU2 7XX, UK
- Department of Physics, University of Surrey, Guildford, GU2 7XH, UK
| | - Dev P Chakraborty
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark D Halling-Brown
- Scientific Computing, Department of Medical Physics, Royal Surrey County Hospital, Guildford, UK
| | - Padraig T Looney
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford, GU2 7XX, UK
| | - Kenneth C Young
- National Coordinating Centre for the Physics in Mammography (NCCPM), Level B, St Luke's Wing, Royal Surrey County Hospital, Guildford, GU2 7XX, UK
- Department of Physics, University of Surrey, Guildford, GU2 7XH, UK
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Evans DG, Thomas S, Caunt J, Roberts L, Howell A, Wilson M, Fox R, Sibbering DM, Moss S, Wallis MG, Eccles DM, Duffy S. Mammographic surveillance in women aged 35-39 at enhanced familial risk of breast cancer (FH02). Fam Cancer 2015; 13:13-21. [PMID: 23733252 DOI: 10.1007/s10689-013-9661-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although there have been encouraging recent studies showing a potential benefit from annual mammography in women aged 40-49 years of age with an elevated breast cancer risk due to family history there is little evidence of efficacy in women aged <40 years of age. A prospective study (FH02) has been developed to assess the efficacy of mammography screening in women aged 35-39 years of age with a lifetime breast cancer risk of ≥ 17 % who are not receiving MRI screening. Retrospective analyses from five centres with robust recall systems identified 47 breast cancers (n = 12 in situ) with an interval cancer rate of 15/47 (32%). Invasive tumour size, lymph node status and current vital status were all significantly better than in two control groups of unscreened women (including those with a family history) recruited to the POSH study. Further evaluation of the prospective arm of FH02 is required to assess the potential added value of digital mammography and the cancer incidence rates in moderate and high risk women in order to inform cost effectiveness analyses.
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Affiliation(s)
- D G Evans
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Trust, Wythenshawe, Manchester, M23 9LT, UK,
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Warren LM, Given-Wilson RM, Wallis MG, Cooke J, Halling-Brown MD, Mackenzie A, Chakraborty DP, Bosmans H, Dance DR, Young KC. The effect of image processing on the detection of cancers in digital mammography. AJR Am J Roentgenol 2014; 203:387-93. [PMID: 25055275 DOI: 10.2214/ajr.13.11812] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2024]
Abstract
OBJECTIVE. The objective of our study was to investigate the effect of image processing on the detection of cancers in digital mammography images. MATERIALS AND METHODS. Two hundred seventy pairs of breast images (both breasts, one view) were collected from eight systems using Hologic amorphous selenium detectors: 80 image pairs showed breasts containing subtle malignant masses; 30 image pairs, biopsy-proven benign lesions; 80 image pairs, simulated calcification clusters; and 80 image pairs, no cancer (normal). The 270 image pairs were processed with three types of image processing: standard (full enhancement), low contrast (intermediate enhancement), and pseudo-film-screen (no enhancement). Seven experienced observers inspected the images, locating and rating regions they suspected to be cancer for likelihood of malignancy. The results were analyzed using a jackknife-alternative free-response receiver operating characteristic (JAFROC) analysis. RESULTS. The detection of calcification clusters was significantly affected by the type of image processing: The JAFROC figure of merit (FOM) decreased from 0.65 with standard image processing to 0.63 with low-contrast image processing (p = 0.04) and from 0.65 with standard image processing to 0.61 with film-screen image processing (p = 0.0005). The detection of noncalcification cancers was not significantly different among the image-processing types investigated (p > 0.40). CONCLUSION. These results suggest that image processing has a significant impact on the detection of calcification clusters in digital mammography. For the three image-processing versions and the system investigated, standard image processing was optimal for the detection of calcification clusters. The effect on cancer detection should be considered when selecting the type of image processing in the future.
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Affiliation(s)
- Lucy M Warren
- 1 National Coordinating Centre for the Physics of Mammography, Royal Surrey County Hospital, NHS Foundation Trust, Guildford, GU2 7XX, UK
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Allen SD, Wallis MG, Cooke R, Swerdlow AJ. Radiologic Features of Breast Cancer after Mantle Radiation Therapy for Hodgkin Disease: A Study of 230 Cases. Radiology 2014; 272:73-8. [DOI: 10.1148/radiol.14131789] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Taylor-Phillips S, Wallis MG, Parsons H, Dunn J, Stallard N, Campbell H, Sellars S, Szczepura A, Gates S, Clarke A. Changing case Order to Optimise patterns of Performance in mammography Screening (CO-OPS): study protocol for a randomized controlled trial. Trials 2014; 15:17. [PMID: 24411004 PMCID: PMC3899604 DOI: 10.1186/1745-6215-15-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/09/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND X-ray mammography remains the predominant test for screening for breast cancer, with the aim of reducing breast cancer mortality. In the English NHS Breast Screening Programme each woman's mammograms are examined separately by two expert readers. The two readers read each batch in the same order and each indicates if there should be recall for further tests. This is a highly skilled, pressurised, repetitive and frequently intellectually unchallenging activity where readers examine one or more batches of 30-50 women's mammograms in each session. A vigilance decrement or performance decrease over time has been observed in similar repetitive visual tasks such as radar operation. METHODS/DESIGN The CO-OPS study is a pragmatic, multi-centre, two-arm, double blind cluster randomised controlled trial of a computer software intervention designed to reduce the effects of a vigilance decrement in breast cancer screening. The unit of randomisation is the batch. Intervention batches will be examined in the opposite order by the two readers (one forwards, one backwards). Control batches will be read in the same order as one another, as is current standard practice. The hypothesis is that cancer detection rates will be higher in the intervention group because each readers' peak performance will occur when examining different women's mammograms. The trial will take place in 44 English breast screening centres for 1 year and 4 months. The primary outcome is cancer detection rate, which will be extracted from computer records after 1 year of the trial. The secondary outcomes include rate of disagreement between readers (a more statistically powerful surrogate for cancer detection rate), recall rate, positive predictive value, and interval cancer rate (cancers found between screening rounds which will be measured three years after the end of the trial). DISCUSSION This is the first trial of an intervention to ameliorate a vigilance decrement in breast cancer screening. TRIAL REGISTRATION ISRCTN46603370 (submitted: 24 October 2012, date of registration: 26 March 2013).
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Fredenberg E, Dance DR, Willsher P, Moa E, von Tiedemann M, Young KC, Wallis MG. Measurement of breast-tissue x-ray attenuation by spectral mammography: first results on cyst fluid. Phys Med Biol 2013; 58:8609-20. [PMID: 24254377 DOI: 10.1088/0031-9155/58/24/8609] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Knowledge of x-ray attenuation is essential for developing and evaluating x-ray imaging technologies. For instance, techniques to better characterize cysts at mammography screening would be highly desirable to reduce recalls, but the development is hampered by the lack of attenuation data for cysts. We have developed a method to measure x-ray attenuation of tissue samples using a prototype photon-counting spectral mammography unit. The method was applied to measure the attenuation of 50 samples of breast cyst fluid and 50 samples of water. Spectral (energy-resolved) images of the samples were acquired and the image signal was mapped to equivalent thicknesses of two known reference materials, which can be used to derive the x-ray attenuation as a function of energy. The attenuation of cyst fluid was found to be significantly different from water. There was a relatively large natural spread between different samples of cyst fluid, whereas the homogeneity of each individual sample was found to be good; the variation within samples did not reach above the quantum noise floor. The spectral method proved stable between several measurements on the same sample. Further, chemical analysis and elemental attenuation calculation were used to validate the spectral measurement on a subset of the samples. The two methods agreed within the precision of the elemental attenuation calculation over the mammographic energy range.
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van Schie G, Wallis MG, Leifland K, Danielsson M, Karssemeijer N. Mass detection in reconstructed digital breast tomosynthesis volumes with a computer-aided detection system trained on 2D mammograms. Med Phys 2013; 40:041902. [PMID: 23556896 DOI: 10.1118/1.4791643] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To develop a computer-aided detection (CAD) system for masses in digital breast tomosynthesis (DBT) which can make use of an existing CAD system for detection of breast masses in full-field digital mammography (FFDM). This approach has the advantage that large digital screening databases that are becoming available can be used for training. DBT is currently not used for screening which makes it hard to obtain sufficient data for training. METHODS The proposed CAD system is applied to reconstructed DBT volumes and consists of two stages. In the first stage, an existing 2D CAD system is applied to slabs composed of multiple DBT slices, after processing the slabs to a representation similar to that of the FFDM training data. In the second stage, the authors group detections obtained in the slabs that detect the same object and determine the 3D location of the grouped findings using one of three different approaches, including one that uses a set of features extracted from the DBT slabs. Experiments were conducted to determine performance of the CAD system, the optimal slab thickness for this approach and the best method to establish the 3D location. Experiments were performed using a database of 192 patients (752 DBT volumes). In 49 patients, one or more malignancies were present which were described as a mass, architectural distortion, or asymmetry. Free response receiver operating characteristic analysis and bootstrapping were used for statistical evaluation. RESULTS Best performance was obtained when slab thickness was in the range of 1-2 cm. Using the feature based 3D localization procedure developed in the study, accurate 3D localization could be obtained in most cases. Case sensitivities of 80% and 90% were achieved at 0.35 and 0.99 false positives per volume, respectively. CONCLUSIONS This study indicates that there may be a large benefit in using 2D mammograms for the development of CAD for DBT and that there is no need to exclusively limit development to DBT data.
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Affiliation(s)
- Guido van Schie
- Department of Radiology, Radboud University Nijmegen Medical Centre, 6500 HB Nijmegen, The Netherlands.
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Rajan S, Foreman J, Wallis MG, Caldas C, Britton P. Multidisciplinary decisions in breast cancer: does the patient receive what the team has recommended? Br J Cancer 2013; 108:2442-7. [PMID: 23736032 PMCID: PMC3694248 DOI: 10.1038/bjc.2013.267] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/08/2013] [Accepted: 05/12/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A multidisciplinary team (MDT) approach to breast cancer management is the gold standard. The aim is to evaluate MDT decision making in a modern breast unit. METHODS All referrals to the breast MDT where breast cancer was diagnosed from 1 July 2009 to 30 June 2011 were included. Multidisciplinary team decisions were compared with subsequent patient management and classified as concordant or discordant. RESULTS Over the study period, there were 3230 MDT decisions relating to 705 patients. Overall, 91.5% (2956 out of 3230) of decisions were concordant, 4.5% (146 out of 3230), were discordant and 4% (128 out of 3230) had no MDT decision. Of 146 discordant decisions, 26 (17.8%) were considered 'unjustifiable' as there was no additional information available after the MDT to account for the change in management. The remaining 120 discordant MDT decisions were considered 'justifiable', as management was altered due to patient choice (n=61), additional information available after MDT (n=54) or MDT error (n=5). CONCLUSION The vast majority of MDT decisions are implemented. Management alteration was most often due to patient choice or additional information available after the MDT. A minority of management alterations were 'unjustifiable' and the authors recommend that any patient whose treatment is subsequently changed should have MDT rediscussion prior to treatment.
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Affiliation(s)
- S Rajan
- Cambridge Breast Unit, Box 97, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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Warren LM, Mackenzie A, Cooke J, Given-Wilson RM, Wallis MG, Chakraborty DP, Dance DR, Bosmans H, Young KC. Effect of image quality on calcification detection in digital mammography. Med Phys 2012; 39:3202-13. [PMID: 22755704 DOI: 10.1118/1.4718571] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study aims to investigate if microcalcification detection varies significantly when mammographic images are acquired using different image qualities, including: different detectors, dose levels, and different image processing algorithms. An additional aim was to determine how the standard European method of measuring image quality using threshold gold thickness measured with a CDMAM phantom and the associated limits in current EU guidelines relate to calcification detection. METHODS One hundred and sixty two normal breast images were acquired on an amorphous selenium direct digital (DR) system. Microcalcification clusters extracted from magnified images of slices of mastectomies were electronically inserted into half of the images. The calcification clusters had a subtle appearance. All images were adjusted using a validated mathematical method to simulate the appearance of images from a computed radiography (CR) imaging system at the same dose, from both systems at half this dose, and from the DR system at quarter this dose. The original 162 images were processed with both Hologic and Agfa (Musica-2) image processing. All other image qualities were processed with Agfa (Musica-2) image processing only. Seven experienced observers marked and rated any identified suspicious regions. Free response operating characteristic (FROC) and ROC analyses were performed on the data. The lesion sensitivity at a nonlesion localization fraction (NLF) of 0.1 was also calculated. Images of the CDMAM mammographic test phantom were acquired using the automatic setting on the DR system. These images were modified to the additional image qualities used in the observer study. The images were analyzed using automated software. In order to assess the relationship between threshold gold thickness and calcification detection a power law was fitted to the data. RESULTS There was a significant reduction in calcification detection using CR compared with DR: the alternative FROC (AFROC) area decreased from 0.84 to 0.63 and the ROC area decreased from 0.91 to 0.79 (p < 0.0001). This corresponded to a 30% drop in lesion sensitivity at a NLF equal to 0.1. Detection was also sensitive to the dose used. There was no significant difference in detection between the two image processing algorithms used (p > 0.05). It was additionally found that lower threshold gold thickness from CDMAM analysis implied better cluster detection. The measured threshold gold thickness passed the acceptable limit set in the EU standards for all image qualities except half dose CR. However, calcification detection varied significantly between image qualities. This suggests that the current EU guidelines may need revising. CONCLUSIONS Microcalcification detection was found to be sensitive to detector and dose used. Standard measurements of image quality were a good predictor of microcalcification cluster detection.
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Affiliation(s)
- Lucy M Warren
- National Co-ordinating Centre for the Physics of Mammography, Royal Surrey County Hospital NHS Foundation Trust, Guildford GU2 7XX, United Kingdom.
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