Leveraging Emergency Department Encounters to Improve Cancer Screening Adherence

OBJECTIVE

We aimed to estimate the proportion of patients visiting the emergency department (ED) who were not up to date with cancer screening guidelines to assess the scope of need and potential impact of ED-based cancer screening interventions.

METHODS

Adult participants from the 2015 National Health Interview Survey were included. Among patients nonadherent to national breast, colorectal, or lung cancer screening guidelines, the proportion of patients reporting an ED visit within the last year was estimated, accounting for complex survey sampling design features. Multiple variable logistic regression analyses were then conducted to evaluate the association between sociodemographic characteristics and screening adherence.

RESULTS

Of screening eligible respondents, 17.2% of women nonadherent to mammography screening, 16.9% of patients nonadherent to colorectal cancer screening, and 25.0% of patients nonadherent to lung cancer screening reported at least one ED visit in the preceding year. Patients visiting the ED with postsecondary school education were more likely to be up to date with mammography screening than those without advanced education (odds ratio [OR] 1.45; 95% confidence interval [CI]: 1.21-1.74; P = .01). Patients without insurance were less likely than those with insurance to report being up to date with both mammography screening (OR 0.31; 95% CI: 0.21-0.48; P = .01) and colorectal cancer screening (OR 0.56; 95% CI: 0.34-0.93; P = .03).

DISCUSSION

Opportunities to improve cancer screening adherence exist through ED-based preventative care interventions, which leverage multidisciplinary partnerships, including radiologists, to reach large volumes of patients who are not engaged in cancer screening.

Opportunities for Radiology Trainee Education Amid the COVID-19 Pandemic: Lessons From an Academic Breast Imaging Program

The COVID-19 pandemic required restructuring of Radiology trainee education across US institutions. While reduced clinical imaging volume and mandates to maintain physical distancing presented new challenges to traditional medical education during this period, new opportunities developed to support our division in providing high-quality training for residents and fellows. The Accreditation Council for Graduate Medical Education (ACGME) Core Competencies for Diagnostic Radiology helped guide division leadership in restructuring and reframing breast imaging education during this time of drastic change and persistent uncertainty. Here, we reflect on the educational challenges and opportunities faced by our academic breast imaging division during the height of the COVID-19 pandemic across each of the ACGME Core Competencies. We also discuss how systems and processes developed out of necessity during the first peak of the pandemic may continue to support radiology training during phased reopening and beyond.

Imaging Surveillance of Breast Cancer Survivors with Digital Mammography versus Digital Breast Tomosynthesis

Background Among breast cancer survivors, detecting a breast cancer when it is asymptomatic (rather than symptomatic) improves survival; thus, imaging surveillance in these patients is warranted. Digital breast tomosynthesis (DBT) is used for screening, but data on DBT for surveillance in this high-risk population are limited. Purpose To determine whether DBT leads to improved screening performance metrics when compared with two-dimensional digital mammography among breast cancer survivors. Materials and Methods In this study, screening mammograms obtained in breast cancer survivors before and after DBT implementation were retrospectively reviewed (March 2008-February 2011 for the digital mammography group; January 2013-December 2017 for the DBT group). Mammograms were interpreted by breast imaging radiologists with the assistance of computer-aided detection. Performance metrics and tumor characteristics between the groups were compared using multivariable logistic regression models. Results The digital mammography and DBT groups were composed of 9019 and 22 887 mammographic examinations, respectively, in 8170 women (mean age, 62 years ± 12 [standard deviation]). In the DBT group, the abnormal interpretation rate was lower (5.8% [1331 of 22 887 examinations] vs 6.2% [563 of 9019 examinations]; odds ratio [OR], 0.80; 95% CI: 0.71, 0.91; P = .001) and specificity was higher (95.0% [21 502 of 22 644 examinations] vs 94.7% [8424 of 8891 examinations]; OR, 1.23; 95% CI: 1.07, 1.41; P = .003) than in the digital mammography group. The cancer detection rates did not differ (8.3 per 1000 examinations with DBT vs 10.6 with digital mammography; OR, 0.76; 95% CI: 0.57, 1.02; P = .07). The proportions of screening-detected invasive cancers, versus in situ cancers, were similar (74% [140 of 189 cancers] in the DBT group vs 72% [69 of 96 cancers] in the digital mammography group; P = .69). Of 86 interval cancers, 58% (50 of 86 cancers) manifested with symptoms, and 33% (28 of 86 cancers) were detected at screening MRI. Conclusion Among breast cancer survivors, screening with digital breast tomosynthesis led to fewer false-positive results and higher specificity but did not affect cancer detection. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Hooley and Butler in this issue.

Screening for Breast Cancer

Among women, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related death in the world. The purpose of this article is to review the evidence regarding breast cancer screening for average-risk women. The review primarily focuses on mammographic screening but also reviews clinical breast examinations, emerging screening technologies, and opportunities to build consensus. Wherever possible, the review relies on published systematic reviews, meta-analyses, and guidelines from three major societies (US Preventive Services Task Force, American College of Radiology, and the American Cancer Society) to reflect a range of evidence-based perspectives regarding mammographic screening.

Ductal Carcinoma In Situ (DCIS) at Breast MRI: Predictors of Upgrade to Invasive Carcinoma

RATIONALE AND OBJECTIVES

To determine the upgrade rate of magnetic resonance imaging (MRI)-detected ductal carcinoma in situ (DCIS) and to identify patient, imaging, and pathologic features that may predict the risk of upgrade.

MATERIALS AND METHODS

Medical chart review from January 2007 to December 2016 identified 60 patients with 61 cases of MRI-detected DCIS and negative mammographic evaluations within 1 year prior to the MRI. Imaging and pathology reports were reviewed. Standard statistical tests, including Student's t-tests and chi-square tests, were used to compare patient, imaging, and pathologic features between the cases of DCIS that did and did not upgrade to invasive carcinoma at surgery.

RESULTS

Over a 10-year period, 60 patients (mean age 52 years, range 30-76 years) were diagnosed with 61 cases of MRI-detected DCIS. Two-thirds of DCIS cases were detected on MRI examinations that were performed for purposes of high-risk screening (67.2%, 41/61). MRI features that led to the DCIS diagnosis were nonmass enhancement in 78.7% (48/61), enhancing mass in 16.4% (10/61), nonmass enhancement and enhancing mass in 3.3% (2/61), and enhancing focus in 1.6% (1/61). Thirteen cases (21.3%, 13/61) were upgraded to invasive ductal carcinoma at surgery. DCIS cases that upgraded were larger on MRI (40 mm vs 17 mm, p < 0.01) and more likely to be associated with comedonecrosis at biopsy (38.5% [5/13] vs 6.3% [3/48], p < 0.01).

CONCLUSION

The upgrade rate of MRI-detected DCIS to invasive ductal carcinoma at surgery is 21.3%. Features that are associated with upgrade include large size on MRI and the presence of comedonecrosis at biopsy.

The Adoption and Impact on Performance of an Automated Outcomes Feedback Application for Tomosynthesis Screening Mammography

OBJECTIVE

To evaluate a tomosynthesis screening mammography automated outcomes feedback application's adoption and impact on performance.

METHODS

This prospective intervention study evaluated a feedback application that provided mammographers subsequent imaging and pathology results for patients that radiologists had personally recalled from screening. Deployed to 13 academic and 5 private practice attending radiologists, adoption was studied from March 29, 2018, to March 20, 2019. Radiologists indicated if reviewed feedback would influence future clinical decisions. For a subset of eight academic radiologists consistently interpreting screening mammograms during the study, performance metrics were compared pre-intervention (January 1, 2016, to September 30, 2017) and post-intervention (October 1, 2017 to June 30, 2018). Abnormal interpretation rate, positive predictive value of biopsies performed, sensitivity, specificity, and cancer detection rate were compared using Pearson's χ² test. Logistic regression models were fit, adjusting for age, race, breast density, prior comparison, breast cancer history, and radiologist.

RESULTS

The 18 radiologists reviewed 68.5% (1,398 of 2,042) of available feedback cases and indicated that 17.4% of cases (243 of 1,398) could influence future decisions. For the eight academic radiologist subset, after multivariable adjustment with comparison to pre-intervention, average abnormal interpretation rate decreased (from 7.5% to 6.7%, adjusted odds ratio [aOR] 0.86, P < .01), positive predictive value of biopsies performed increased (from 40.6% to 51.3%, aOR 1.48, P = .011), and specificity increased (from 93.0% to 93.9%, aOR 1.17, P < .01) post-intervention. There was no difference in cancer detection rate per 1,000 examinations (from 5.8 to 6.1, aOR 1.01, P = .91) or sensitivity (from 81.2% to 78.7%, aOR 0.84, P = .47).

CONCLUSIONS

Radiologists used a screening mammography automated outcomes feedback application. Its use decreased false-positive examinations, without evidence of reduced cancer detection.

Do Eligibility Criteria for Ductal Carcinoma In Situ (DCIS) Active Surveillance Trials Identify Patients at Low Risk for Upgrade to Invasive Carcinoma?

BACKGROUND

Clinical trials are currently ongoing to determine the safety and efficacy of active surveillance (AS) versus usual care (surgical and radiation treatment) for women with ductal carcinoma in situ (DCIS). This study aimed to determine upgrade rates of DCIS at needle biopsy to invasive carcinoma at surgery among women who meet the eligibility criteria for AS trials.

METHODS

A retrospective review was performed of consecutive women at an academic medical center with a diagnosis of DCIS at needle biopsy from 2007 to 2016. Medical records were reviewed for mode of presentation, imaging findings, biopsy pathology results, and surgical outcomes. Each patient with DCIS was evaluated for AS trial eligibility based on published criteria for the COMET, LORD, and LORIS trials.

RESULTS

During a 10-year period, DCIS was diagnosed in 858 women (mean age 58 years; range 28-89 years). Of the 858 women, 498 (58%) were eligible for the COMET trial, 101 (11.8%) for the LORD trial, and 343 (40%) for the LORIS trial. The rates of upgrade to invasive carcinoma were 12% (60/498) for the COMET trial, 5% (5/101) for the LORD trial, and 11.1% (38/343) for the LORIS trial. The invasive carcinomas ranged from 0.2 to 20 mm, and all were node-negative.

CONCLUSIONS

Women who meet the eligibility criteria for DCIS AS trials remain at risk for occult invasive carcinoma at presentation, with upgrade rates ranging from 5 to 12%. These findings suggest that more precise criteria are needed to ensure that women with invasive carcinoma are excluded from AS trials.

Impact of Background Parenchymal Enhancement on Diagnostic Performance in Screening Breast MRI

RATIONALE AND OBJECTIVES

To evaluate the impact of background parenchymal enhancement (BPE) on diagnostic performance in screening breast magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Consecutive screening breast MRIs performed at our institution from 2011 to 2014 were reviewed in a HIPAA-compliant manner with institutional review board approval. BPE was extracted from radiology reports and examinations grouped into minimal/mild (lower) or moderate/marked (higher) BPE. Performance measures were compared between the two groups with Pearson's χ2 test and with logistic regression to adjust for possible confounders of age, screening indication, mammographic density, available prior MRI, and examination year, using lower BPE as the reference group.

RESULTS

For 4686 screening MRIs performed in 2446 women, BPE was reported as minimal or mild for 3975 (85%) examinations and moderate or marked for 711(15%). Following logistic regression to adjust for multiple confounders, abnormal interpretation rate (AIR) significantly differed between the two BPE groups. AIR was 13% (89/711) in the higher BPE group versus 7% (295/3975) in the lower BPE group with an adjusted odds ratio of 1.37 (95% confidence interval: 1.03, 1.82). After adjustment, all other performance metrics, including cancer detection rate, positive predictive value, sensitivity, and specificity did not significantly differ between the two BPE groups (P > 0.05).

CONCLUSION

Higher BPE on screening MRI is associated with higher abnormal interpretation rate, with no impact on cancer detection rate, sensitivity, or specificity.

Kinetic Analysis of Lesions Identified on a Rapid Abridged Multiphase (RAMP) Breast MRI Protocol

RATIONALE AND OBJECTIVES

We implemented a rapid abridged multiphase (RAMP) breast magnetic resonance imaging (MRI) protocol to reduce scan time and increase workflow efficiency. In this study, we compared delayed-phase kinetic analyses of benign and malignant lesions on the RAMP protocol versus a full dynamic contrast-enhanced (DCE) MRI protocol.

MATERIALS AND METHODS

Consecutive breast MRI examinations obtained from October 2015 to August 2016 with tissue diagnoses of suspicious MRI lesions were identified. RAMP MRI included one precontrast and two postcontrast phases. Full DCE MRI included one precontrast and at least three postcontrast phases. Lesion kinetic analyses including mean delayed-phase volume percentage of washout, predominant curve type, and worst curve type were assessed. Kinetic analyses assessed on RAMP and DCE MRI protocols were compared using Wilcoxon rank-sum test and Chi-Square test. Receiver operating characteristic analysis was performed to discriminate benign and malignant lesions based on delayed-phase parameters.

RESULTS

The study included 177 consecutive breast lesions (50 benign, 127 malignant) in 162 women. RAMP MRI (23 benign, 61 malignant) and DCE MRI examinations (27 benign, 66 malignant) demonstrated 8.4% vs 9.3% washout (p = 0.36) for benign lesions and 18.5% vs 17% washout (p = 0.66) for malignancies, respectively. There was no difference in the predominant and worst curve types for malignant and benign lesions or in area under the receiver operating characteristic curves for delayed-phased parameters between the two protocols (p > 0.05).

CONCLUSION

Lesion kinetic analyses from the RAMP MRI protocol can achieve the same discriminatory ability as the full DCE protocol. By reducing scan time, the RAMP MRI protocol improves patient comfort and enhances workflow efficiency and can be easily implemented in any clinical setting.

Breast Cancer Screening with Digital Breast Tomosynthesis: Are Initial Benefits Sustained?

Background Performance metrics with digital breast tomosynthesis (DBT) are based on early experiences. There is limited research on whether the benefits of DBT are sustained. Purpose To determine whether improved screening performance metrics with DBT are sustained over time at the population level and after the first screening round at the individual level. Materials and Methods A retrospective review was conducted of screening mammograms that had been obtained before DBT implementation (March 2008 to February 2011, two-dimensional digital mammography [DM] group) and for 5 years after implementation (January 2013 to December 2017, DBT1-DBT5 groups, respectively). Patients who underwent DBT were also categorized according to the number of previous DBT examinations they had undergone. Performance metrics were compared between DM and DBT groups and between patients with no previous DBT examinations and those with at least one prior DBT examination by using multivariable logistic regression models. Results The DM group consisted of 99 582 DM examinations in 55 086 women (mean age, 57.3 years ± 11.6 [standard deviation]). The DBT group consisted of 205 048 examinations in 76 276 women (mean age, 58.2 years ± 11.2). There were no differences in the cancer detection rate (CDR) between DM and DBT groups (4.6-5.8 per 1000 examinations, P = .08 to P = .95). The highest CDR was observed with a woman's first DBT examination (6.1 per 1000 examinations vs 4.4-5.7 per 1000 examinations with at least one prior DBT examination, P = .001 to P = .054). Compared with the DM group, the DBT1 group had a lower abnormal interpretation rate (AIR) (adjusted odds ratio [AOR], 0.85; P < .001), which remained reduced in the DBT2, DBT3, and DBT5 groups (P < .001 to P = .02). The reduction in AIR was also sustained after the first examination (P < .001 to P = .002). Compared with the DM group, the DBT1 group had a higher specificity (AOR, 1.20; P < .001), which remained increased in DBT2, DBT3, and DBT5 groups (P < .001 to P = .004). The increase in specificity was also sustained after the first examination (P < .001 to P = .01). Conclusion The benefits of reduced false-positive examinations and higher specificity with screening tomosynthesis were sustained after the first screening round at the individual level. © RSNA, 2020 See also the editorial by Taourel in this issue.

The Impact of Preoperative Breast MRI on Surgical Management of Women with Newly Diagnosed Ductal Carcinoma In Situ

RATIONALE AND OBJECTIVES

Use of preoperative breast MRI (pMRI) to evaluate ductal carcinoma in situ (DCIS) extent is controversial due to limited data on its impact on surgical management. We sought to evaluate the effect of pMRI on surgical management of women with core needle biopsy (CNB)-diagnosed pure DCIS at a multidisciplinary academic institution.

MATERIALS AND METHODS

This retrospective study included all women with CNB-diagnosed DCIS (1/2004-12/2013) without prior ipsilateral breast cancer and who underwent surgery within 180 days of diagnosis. Patient features, number of CNBs and surgeries, and single successful breast conserving surgery (BCS) rate were compared between pMRI and no-pMRI cohorts. Number of surgeries and single BCS success rates were also compared to published US (SEER) and Danish National Registry data.

RESULTS

Among the 373 women included, no clinical differences were identified between the pMRI (n = 332) and no-pMRI (n = 41) cohorts (p > 0.05). The pMRI group experienced a higher additional CNB rate (30% vs. 7%, p = 0.002) but fewer total surgeries (mean = 1.2 vs. 1.5, p < 0.001) than the no-pMRI group. Among the 245 women for whom BCS was attempted, the pMRI cohort underwent fewer mean surgeries (1.3 vs. 1.7, p < 0.001) with a greater single successful BCS rate (77% vs. 43%, p < 0.001). Compared to published data, women with pMRI who underwent BCS experienced fewer surgeries (difference (Δ) = -0.22 vs. -0.17, p < 0.001) with a higher single successful BCS rate (Δ = +20% vs. +14%, p < 0.001).

CONCLUSION

pMRI may improve surgical management of DCIS at multidisciplinary centers with breast cancer specialists.

Breast Cancer Screening in Puerto Rico and Other US Territories: Findings from the 2016 Behavioral Risk Factor Surveillance System Survey

Initial studies suggest that women living in U.S. territories may experience barriers to appropriate breast cancer diagnosis and treatment. Our purpose was to evaluate mammography screening engagement in U.S. territories compared with U.S. states. Women aged 50-74 years in the 2016 Behavioral Risk Factor Surveillance System survey without personal history of breast cancer were included. Proportions of women reporting mammography use were calculated. Multivariable logistic regression models were used to compare self-reported mammography use in U.S. territories with all U.S. states. Our total study population included 131,320 women. Of this group, 2,481 were from U.S. territories. In our adjusted analyses, women in the U.S. Virgin Islands were less likely to report mammography use (OR 0.52) compared with women in the U.S. states. Women in other U.S. territories reported mammography at similar rates to U.S. states. Targeted interventions accounting for unique, territory-specific barriers are likely required to improve screening engagement.

Association of Magnetic Resonance Imaging and a 12-Gene Expression Assay With Breast Ductal Carcinoma In Situ Treatment

Importance

Advanced diagnostics, such as magnetic resonance imaging (MRI) and gene expression profiles, are potentially useful to guide targeted treatment in patients with ductal carcinoma in situ (DCIS).

Objectives

To examine the proportion of patients who converted to mastectomy after MRI and the reasons for those conversions and to measure patient adherence to radiotherapy guided by the 12-gene DCIS score.

Design, Setting, and Participants

Analysis of a prospective, cohort, nonrandomized clinical trial that enrolled women with DCIS on core biopsy who were candidates for wide local excision (WLE) from 75 institutions from March 25, 2015, to April 27, 2016, through the Eastern Cooperative Oncology Group-American College of Radiology Imaging Network trial E4112.

Interventions

Participants underwent breast MRI before surgery, and subsequent management incorporated MRI findings for choice of surgery. The DCIS score was used to guide radiotherapy recommendations among women with DCIS who had WLE as the final procedure and had tumor-free excision margins of 2 mm or greater.

Main Outcomes and Measures

The primary end point was to estimate the conversion rate to mastectomy and the reason for conversion.

Results

Of 339 evaluable women (mean [SD] age, 59.1 [10.1] years; 262 [77.3%] of European descent) eligible for WLE before MRI, 65 (19.2%; 95% CI, 15.3%-23.7%) converted to mastectomy. Of these 65 patients, conversion was based on MRI findings in 25 (38.5%), patient preference in 25 (38.5%), positive margins after attempted WLE in 10 (15.4%), positive genetic test results in 3 (4.6%), and contraindication to radiotherapy in 2 (3.1%). Among the 285 who had WLE performed after MRI as the first surgical procedure, 274 (96.1%) achieved successful breast conservation. Of 171 women eligible for radiotherapy guided by DCIS score (clear margins, absence of invasive disease, and score obtained), the score was low (<39) in 82 (48.0%; 95% CI, 40.6%-55.4%) and intermediate-high (≥39) in 89 (52.0%; 95% CI, 44.6%-59.4%). Of these 171 patients, 159 (93.0%) were adherent with recommendations.

Conclusions and Relevance

Among women with DCIS who were WLE candidates based on conventional imaging, multiple factors were associated with conversion to mastectomy. This study may provide useful preliminary information required for designing a planned randomized clinical trial to determine the effect of MRI and DCIS score on surgical management, radiotherapy, overall resource use, and clinical outcomes, with the ultimate goal of achieving greater therapeutic precision.

Trial Registration

ClinicalTrials.gov identifier: NCT02352883.

The Effect of Prior Comparison MRI on Interpretive Performance of Screening Breast MRI

OBJECTIVE

To evaluate the effect of prior comparison MRI on interpretive performance of screening breast MRI.

METHODS

After institutional review board approval, all screening breast MRI examinations performed from January 2011 through December 2014 were retrospectively reviewed. Screening performance metrics were estimated and compared for exams with and without a prior comparison MRI, using logistic regression models to adjust for age and screening indication (BRCA mutation or thoracic radiation versus breast cancer history versus high-risk lesion history versus breast cancer family history).

RESULTS

Most exams, 4509 (87%), had a prior comparison MRI (incidence round), while 661 (13%) did not (prevalence round). Abnormal interpretation rate (6% vs 20%, P < 0.01), biopsy rate (3% vs 9%, P < 0.01), and false-positive biopsy recommendation rate per 1000 exams (21 vs 71, P < 0.01) were significantly lower in the incidence rounds compared to the prevalence rounds, while specificity was significantly higher (95% vs 81%, P < 0.01). There was no difference in cancer detection rate (CDR) per 1000 exams (12 vs 20, P = 0.1), positive predictive value of biopsies performed (PPV3) (35% vs 23%, P = 0.1), or sensitivity (86% vs 76%, P = 0.4).

CONCLUSION

Presence of a prior comparison significantly improves incidence round screening breast MRI examination performance compared with prevalence round screening. Consideration should be given to updating the BI-RADS breast MRI screening benchmarks and auditing prevalence and incidence round examinations separately.

Patient-Assisted Compression in Screening Mammography: Patient Experience and Image Quality

OBJECTIVE

Screening mammography is critical to reduce breast cancer mortality, yet many women cite pain from compression as a reason they avoid this test. We evaluated patient experience and image quality in screening patients opting for a handheld patient-assisted compression (PAC) device.

METHODS

After institutional review board approval, women screened between February and July 2018 with a synthetic 2D/tomosynthesis mammography unit were offered use of a handheld PAC device. Patient experience through survey, image quality, compression thickness, compression force, and average glandular dose were evaluated and compared between women opting for PAC and women opting for technologist-controlled compression (TC). Multivariable ordinal logistic and linear regression models were estimated to control for age and breast density. In addition, for women opting for PAC, image quality obtained with their current PAC mammogram was compared with that obtained with their prior TC mammogram, by using Wilcoxon/Pearson tests.

RESULTS

Seventy-three percent of women preferred their mammogram experience with PAC compared with their prior mammogram without PAC. Women using PAC reported decreased anxiety compared with those using TC, after controlling for age and breast density (adjusted odds ratio [aOR] 0.22 [95% confidence interval (CI): 0.09-0.49]). There were no significant differences in image quality, compression thickness, or average glandular dose in exams for women using PAC compared with exams for women using TC. Women using PAC had significantly more compression force than women using TC had (P = 0.012).

CONCLUSIONS

Mammography with PAC improves patient experience and results in similar image quality compared with mammography with TC.

Obesity and breast cancer screening: Cross-sectional survey results from the behavioral risk factor surveillance system

BACKGROUND

Postmenopausal obese women demonstrate an elevated breast cancer risk and experience increased breast cancer morbidity and mortality compared with women with a normal body mass index (BMI). However, to the authors' knowledge, prior studies have yielded inconclusive results regarding the effects of obesity on mammography screening adherence. Using national cross-sectional survey data, the objective of the current study was to assess the current association between increasing BMI and use of mammography screening.

METHODS

Cross-sectional survey data from the 2016 Behavioral Risk Factor Surveillance System, a state-based national telephone survey of noninstitutionalized adults in the United States, was used to identify the association between mammography screening use and increasing incremental BMI categories, including normal (18.5-24.9 kg/m² ), overweight (25-29.9 kg/m² ), obese class I (30-34.9 kg/m² ), obese class II (35-39.9 kg/m² ), and obese class III (>40 kg/m² ), with adjustments for potential confounders. A multivariable logistic regression model was used to evaluate the effect of each BMI category on self-reported mammography use, using unadjusted and adjusted odds ratios. Effect modification by race/ethnicity was determined by testing interaction terms using Wald tests.

RESULTS

Of 116,343 survey respondents, 33.5% (38,984 respondents) had a normal BMI, 32.6% (37,969 respondents) were overweight, 19.3% (22,416 respondents) were classified as obese class I, 8.4% (9791 respondents) were classified as obese class II, and 6.2% (7183 respondents) were classified as obese class III. There was no statistically significant difference (P < .05) observed with regard to mammography use between women with a normal BMI and obese women from each obese class (classes I-III) when compared individually. There also was no evidence of effect modification by race (P = .53).

CONCLUSIONS

In contrast to prior reports, the results of the current study demonstrated no association between obesity and adherence to screening mammography. These findings may relate to the increasing social acceptance of obesity among women from all racial/ethnic groups and the removal of weight-related facility-level barriers over time.

Surveillance Breast MRI and Mammography: Comparison in Women with a Personal History of Breast Cancer

Background There is lack of consensus regarding the use of breast MRI for routine surveillance for second breast cancer events in women with a personal history of breast cancer. Purpose To compare performance of surveillance mammography with breast MRI. Materials and Methods This observational cohort study used prospectively collected data and included 13 266 women age 18 years and older (mean age, 60 years ± 13) with stage 0-III breast cancer who underwent 33 938 mammographic examinations and 2506 breast MRI examinations from 2005 to 2012 in the Breast Cancer Surveillance Consortium. Women were categorized into two groups: mammography alone (n = 11 745) or breast MRI (n = 1521). Performance measures were calculated by using end-of-day assessment and occurrence of second breast cancer events within 1 year of imaging. Logistic regression was used to compare performance for breast MRI versus mammography alone, adjusting for women, examination, and primary breast cancer characteristics. Analysis was conducted on a per-examination basis. Results Breast MRI was associated with younger age at diagnosis, chemotherapy, and higher education and income. Raw performance measures for breast MRI versus mammography were as follows, respectively: cancer detection rates, 10.8 (95% confidence interval [CI]: 6.7, 14.8) versus 8.2 (95% CI: 7.3, 9.2) per 1000 examinations; sensitivity, 61.4% (27 of 44; 95% CI: 46.5%, 76.2%) versus 70.3% (279 of 397; 95% CI: 65.8%, 74.8%); and biopsy rate, 10.1% (253 of 2506; 95% CI: 8.9%, 11.3%) versus 4.0% (1343 of 33 938; 95% CI: 3.7%, 4.2%). In multivariable models, breast MRI was associated with higher biopsy rate (odds ratio [OR], 2.2; 95% CI: 1.9, 2.7; P < .001) and cancer detection rate (OR, 1.7; 95% CI: 1.1, 2.7; P = .03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI: 0.4, 2.9; P = .84) or interval cancer rate (OR, 1.1; 95% CI: 0.6, 2.2; P = .70). Conclusion Comparison of the performance of surveillance breast MRI with mammography must account for patient characteristics. Whereas breast MRI leads to higher biopsy and cancer detection rates, there were no significant differences in sensitivity or interval cancers compared with mammography. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Newell in this issue.

Influence of Menstrual Cycle Timing on Screening Breast MRI Background Parenchymal Enhancement and Diagnostic Performance in Premenopausal Women

Purpose

To assess the influence of menstrual cycle timing on background parenchymal enhancement (BPE) and performance on screening breast magnetic resonance imaging (MRI) in premenopausal women at high risk for developing breast cancer.

Methods

After Institutional Review Board approval, all screening breast MRIs performed from January 2007 through November 2010 in premenopausal women in whom day from last menstrual period was recorded were identified. Prospectively recorded BPE levels and Breast Imaging Reporting and Data System MRI assessments were extracted from our database. Subject outcomes were determined by using biopsy, imaging follow-up, and linkage with the regional tumor registry (minimum 12-month follow-up). Associations of BPE levels (minimal/mild versus moderate/marked) with menstrual cycle phase (follicular [day 0-15] versus luteal [day 16-35]) and week (1, 2, 3, or 4) were compared. Differences in MRI performance metrics, including abnormal interpretation rate (AIR), positive biopsy rate (PBR), cancer yield, sensitivity, and specificity, were compared between menstrual cycle phase and menstrual cycle week.

Results

Three-hundred twenty examinations in 244 premenopausal women met inclusion criteria with nine cancers diagnosed. BPE levels were not associated with menstrual cycle phase or week (P > 0.05). MRI performance metrics (ie, AIR, PBR, cancer yield, sensitivity, or specificity) did not differ significantly based on menstrual cycle phase or menstrual cycle week (P > 0.05).

Conclusions

Obtaining screening breast MRI exams during specific phases or weeks of the menstrual cycle in premenopausal women does not reliably produce MRI examinations with lower BPE levels or improved performance.

Impact of a Same-Day Breast Biopsy Program on Disparities in Time to Biopsy

BACKGROUND

Disparities in breast cancer diagnosis are established. In usual practice, biopsies are performed days or weeks after recommendation. Our aim was to measure the impact of a same-day biopsy program on disparities in time from biopsy recommendation to performance.

METHODS

After Institutional Review Board approval, we identified all diagnostic examinations leading to biopsy pre- (September 2016 to March 2017) and post- (September 2017 to March 2018) implementation of our same-day biopsy program. We compared demographic characteristics (age, race, language, and insurance) and biopsy information (days from biopsy recommendation to biopsy, and proportion of same-day biopsies in all biopsies) in pre- versus postimplementation groups. Multivariable linear and logistic models in pre- and postimplementation groups assessed if days from biopsy recommendation to biopsy and having a same-day biopsy were associated with patient subgroups.

RESULTS

In all, 663 and 482 patients underwent biopsy during pre- and postimplementation periods, respectively. Patient subgroups were similar between periods. For all patients, the same-day biopsy program decreased median time from diagnostic examination to biopsy from 8 (interquartile range: 4-13) to 0 (interquartile range: 0-4) days (P < .001). During the pre-implementation period, nonwhite patients and having Medicare insurance were associated with longer days to biopsy (nonwhite Adjusted Coefficient: 2.31, 95% confidence interval [CI]: 0.58-4.03; insurance Adjusted Coefficient: 2.47, 95% CI: 0.58-4.37; P < .05), after adjustment. During the postimplementation period, the previously seen disparities did not persist (nonwhite Adjusted Coefficient: -0.416, 95% CI: -2.16-1.33; insurance Adjusted Coefficient: 0.812, 95% CI: -1.18-2.80; P > .05).

CONCLUSION

There was no evidence of racial/ethnic or insurance disparities in time from biopsy recommendation to performance after implementation of a same-day biopsy program.

Assessing Eligibility for Lung Cancer Screening Among Women Undergoing Screening Mammography: Cross-Sectional Survey Results From the National Health Interview Survey

PURPOSE

Millions of women undergo mammography screening each year, presenting an opportunity for radiologists to identify women eligible for lung cancer screening (LCS) with low-dose chest CT and smoking cessation counseling. The purpose of our study was to estimate the proportion of women eligible for LCS and tobacco cessation counseling among women reporting mammography screening within the previous 2 years using nationally representative cross-sectional survey data.

METHODS

Women between the ages of 55 and 74 years in the 2015 National Health Interview Survey without history of lung or breast cancer who reported mammography use in the previous 2 years were included. The primary outcome was the weighted proportion of women eligible for LCS. Secondary outcomes included self-reported receipt of LCS and current smoking. Bivariate and multiple variable logistic regression analyses were performed to evaluate the association between primary and secondary outcomes and sociodemographics, accounting for complex survey design elements.

RESULTS

Among 3,806 women meeting inclusion criteria, 7.1% were eligible for LCS and 9.8% were current smokers. Multivariable analyses demonstrated that LCS-eligible women were more likely to be white, younger, and non-college-educated and have lower household incomes (all P < .001). Among all LCS-eligible women, 58% reported undergoing mammography screening within the previous 2 years. Among LCS-eligible women who underwent screening mammography, 7.9% reported undergoing LCS.

CONCLUSIONS

The majority of LCS-eligible women received mammography screening but did not receive LCS. Mammography encounters may represent prime opportunities to increase LCS participation among patients already receiving imaging-based screening services.