The association between obesity and screening mammography accuracy

Impact of body mass index and examination type on utilization of screening programs: A big data study

OBJECTIVE

To investigate the relationship between Body Mass Index (BMI) and adherence to recommended screening tests, addressing gaps in previous literature by utilizing a large cohort, while considering longitudinal changes in weight and the type of screening.

METHODS

Data from Clalit Health Services in Israel were retrospectively analyzed, including participants aged 50 and above from 2002 to 2021. BMI measurements and various screening test records were examined. Generalized Estimating Equations were employed for analysis, adjusting for potential confounding variables, including age, gender, geographic location, and socioeconomic status.

RESULTS

The study included 634,879 participants with 4,630,030 BMI measurements and 56,453,659 test records. Participants were categorized into BMI cohorts at the time of the test, with overweight and obese individuals showing lower odds of undergoing intimate examination-based screening tests (mammography, PAPS, and skin examination), as opposed to higher odds of several non-intimate tests (e.g., diabetes and eye disorder screenings).

DISCUSSION

Our findings suggest that individuals with overweight and obesity are less likely to undergo screenings involving intimate physical examinations, potentially due to weight stigma and discomfort. This avoidance behavior may contribute to increased morbidity rates in these populations. Interventions addressing weight stigma, improving access to care, and enhancing patient engagement are warranted.

Bridging Gaps: Analyzing Breast Imaging-Reporting and Data System (BI-RADS) 0 Rates and Associated Risk Factors in Disproportionally Affected Communities

Introduction Disparities in access to breast cancer screening led to the creation of the Linda Fenner 3D Mobile Mammography Center (LFMMC), successfully increasing screening for uninsured women in Miami-Dade. However, a higher-than-expected rate of inconclusive mammograms (Breast Imaging-Reporting and Data System (BI-RADS) 0) was found, which could lead to unnecessary procedures, stress, costs, and radiation. Methods In this retrospective cross-sectional study, we analyzed data from 3,044 uninsured women aged over 40 (younger if positive family history of breast cancer) from Miami-Dade without breast symptoms or breast cancer history. Women's demographic characteristics, primary language spoken, body mass index (BMI), use of hormone replacement therapy and birth control, history of benign biopsy, breast surgery, family breast cancer, and menopausal status were assessed as potential risk factors for an inconclusive (BI-RADS 0) screening mammogram result. Multivariable logistic regression analyses were used to evaluate associations. Results The average age of women was 51 years (SD = 9); 59% were White, and 30% were African American. The overall frequency of BI-RADS 0 was 35%. Higher odds of BI-RADS 0 were found for women who were younger, single, premenopausal, and with benign biopsy history. Conversely, obesity and breast implant history decreased the odds of BI-RADS 0. Conclusion We found a high frequency of BI-RADS 0 in the LFMMC sample. Potential reasons include a higher risk for breast cancer or a younger sample of women screened. Future research should explore radiologists' reasoning for assigning BI-RADS 0 results and testing alternative screening strategies for younger women.

The Effects of Obesity on Health Care Delivery

The rates of obesity continue to rise among adults and children in the United States; hence, it is natural that obesity is reshaping health care delivery. This is seen in numerous ways, including physiologic, physical, social, and economic impacts. This article reviews a broad range of topics, from the effects of increased adiposity on drug pharmacokinetics and pharmacodynamics to the changes health care environments are making to accommodate patients with obesity. The significant social impacts of weight bias are reviewed, as are the economic consequences of the obesity epidemic. Finally, a patient case that demonstrates the effects of obesity on health care delivery is examined.

Disparities in Breast Cancer Outcomes and How to Resolve Them

There has been a 40% decline in breast cancer age-adjusted death rate since 1990. Black American women have not experienced as great a decline; indeed, the Black-White disparity in mortality in the United States is greater today than it has ever been. Certain states (areas of residence), however, do not see such dramatic differences in outcome by race. This latter finding suggests much more can be done to reduce disparities and prevent deaths. Interventions to get high-quality care (screening, diagnostics, and treatment) involve understanding the needs and concerns of the patient and addressing those needs and concerns. Patient navigators are 1 way to improve outcomes.

Diagnostic Accuracy of Opportunistic Breast Cancer Screening Based on Mammography in Iran

Background: Although breast cancer is the most prevalent type of cancer among Iranian women, its screening is opportunistic in Iran. The available guidelines for breast cancer screening are based on mammography. A screening modality should have adequate diagnostic accuracy and be widely available at reasonable cost. Although mammography is highly accessible in Iran, its accuracy has not been investigated. Objectives: This study aimed to evaluate the accuracy of mammography in opportunistic screening regarding the current rate of patient attendance. Patients and Methods: A total of 491 women undergoing screening mammography were followed-up based on their medical records. They were divided into positive and negative screening groups, based on the breast imaging-reporting and data system (BI-RADS) categories and approaches. To evaluate the disease status of positive cases, pathology reports were investigated, and negative cases were followed-up for stability over time. Results: In the study sample, sensitivity was estimated at 73.08% (95% CI: 55.21 - 88.93), specificity was estimated at 94.41% (95% CI: 91.91 - 96.32), and accuracy was 93.28% (95% CI: 90.69 - 95.33). These test accuracy indices were not significantly different between the groups regarding age, family history, breast density, and history of breast interventions. Conclusion: The test’s sensitivity or ability to detect a disease was relatively low in opportunistic screening; it was found to be similar to the results of studies of first time implementation of screeninng. In both settings, a test needs to diagnose both incident and prevalent cases. The overall accuracy of mammography was acceptable, even in opportunistic screening.

Body Mass Index Is Inversely Associated with Risk of Postmenopausal Interval Breast Cancer: Results from the Women's Health Initiative

Interval breast cancer refers to cancer diagnosed after a negative screening mammogram and before the next scheduled screening mammogram. Interval breast cancer has worse prognosis than screening-detected cancer. Body mass index (BMI) influences the accuracy of mammography and overall postmenopausal breast cancer risk, yet how is obesity associated with postmenopausal interval breast cancer incidence is unclear. The current study included cancer-free postmenopausal women aged 50-79 years at enrollment in the Women's Health Initiative who were diagnosed with breast cancer during follow-up. Analyses include 324 interval breast cancer cases diagnosed within one year after the participant's last negative screening mammogram and 1969 screening-detected breast cancer patients. Obesity (BMI ≥ 30 kg/m2) was measured at baseline. Associations between obesity and incidence of interval cancer were determined by sequential logistic regression analyses. In multivariable-adjusted models, obesity was inversely associated with interval breast cancer risk [OR (95% CI) = 0.65 (0.46, 0.92)]. The inverse association persisted after excluding women diagnosed within 2 years [OR (95% CI) = 0.60 (0.42, 0.87)] or 4 years [OR (95% CI) = 0.56 (0.37, 0.86)] of enrollment, suggesting consistency of the association regardless of screening practices prior to trial entry. These findings warrant confirmation in studies with body composition measures.

Association Between Obesity and Clinicopathological Profile of Patients with Newly Diagnosed Non-Metastatic Breast Cancer in Saudi Arabia

Purpose

Obesity is prevalent in Saudi Arabia and is associated with adverse clinical features and poor breast cancer (BC) outcomes. We determined the distribution of body mass index (BMI) and evaluated its association with disease characteristics and outcomes in women with non-metastatic BC.

Patients and Methods

We conducted a retrospective analysis of a prospectively collected database of consecutive patients treated for non-metastatic BC between 2002 and 2014. Patients were categorized into the following groups: underweight/normal weight (BMI <25 kg/m²), overweight (BMI 25–29.9 kg/m²), and obese (BMI ≥30 kg/m²). Regression analysis was used to evaluate clinicopathological factors associated with BMI and clinical stage.

Results

A total of 2212 patients were enrolled. The median age was 45 years (interquartile range [IQR], 39–52 years), and the median BMI was 30 kg/m² (IQR, 26–34 kg/m²). Most patients were premenopausal (63.6%), nearly half of the patients had stage III disease, and 11.2% were screen-detected. The prevalence of obesity was 53.4%, with a significant difference between the peri/premenopausal (49.4%) and postmenopausal (61.7%) groups (p < 0.001). Obese patients were more likely to be aged >40 years, be postmenopausal, have a history of oral contraceptive pills, have advanced-stage disease, and have undergone radiation therapy, and were less likely to have human epithelial growth factor 2 (HER2)+ disease than non-obese patients. Premenopausal obese women had fewer hormone receptor-positive and more triple-negative cancers than postmenopausal obese women did. Obesity, non-screening-detected BC, and HER+ status were independent prognostic factors for advanced-stage presentation.

Conclusion

The prevalence of obesity and its significant association with advanced BC justify the upscaling of screening services and instituting weight-reduction strategies.

A review of screening mammography: The benefits and radiation risks put into perspective

INTRODUCTION/BACKGROUND

In medical imaging a benefit to risk analysis is required when justifying or implementing diagnostic procedures. Screening mammography is no exception and in particular concerns around the use of radiation to help diagnose cancer must be addressed.

METHODS

The Medline database and various established reports on breast screening and radiological protection were utilised to explore this review.

RESULTS/DISCUSSION

The benefit of screening is well argued; the ability to detect and treat breast cancer has led to a 91% 5-year survival rate and 497 deaths prevented from breast cancer amongst 100,000 screened women. Subsequently, screening guidelines by various countries recommend annual, biennial or triennial screening from ages somewhere between 40-74 years. Whilst the literature presents different perspectives on screening younger and older women, the current evidence of benefit for screening women <40 and ≥75 years is currently not strong. The radiation dose and associated risk delivered to each woman for a single examination is dependent upon age, breast density and breast thickness, however the average mean glandular dose is around 2.5-3 mGy, and this would result in 65 induced cancers and 8 deaths per 100,000 women over a screening lifetime from 40-74 years. This results in a ratio of lives saved to deaths from induced cancer of 62:1.

CONCLUSION

Therefore, compared to the potential mortality reduction achievable with screening mammography, the risk is small.

Relationship between body mass index and malignancy rates of MRI-guided breast biopsies: impact of clinicodemographic factors

PURPOSE

To determine the positive predictive value (PPV) of magnetic resonance imaging (MRI)-guided breast biopsy stratified by body mass index (BMI). Secondary endpoints include evaluation of indications for breast MRI and identification of factors associated with malignant biopsy.

METHODS

We retrospectively analyzed results of MRI-guided breast biopsies in a consecutive cohort of women at a single institution between 2014 and 2019. The PPV was compared between BMI subgroups and the overall group by the one-sample z-test. Factors associated with malignant biopsy were analyzed using multivariate regression analysis.

RESULTS

Among 427 MRI-guided breast biopsies, the PPV was significantly higher in patients with a BMI ≥ 35 compared to BMI < 35 (38.6% versus 24.5%, p = 0.043). This remained true in the 180 biopsies from high-risk screening studies, but there was no difference in PPV by BMI in the 205 biopsies performed to evaluate extent of known disease. Among this cohort who underwent MRI-guided breast biopsy, the underlying indication for MRI was less likely to be high-risk screening in those with a higher BMI or Black or Hispanic race (p = 0.015 and p < 0.001, respectively). For high-risk screening studies, only BMI ≥ 35 was associated with malignant biopsies (OR 37.5, p = 0.003). For evaluation of extent of disease studies, only increased lesion size was a significant predictor of malignant result (OR 1.01, p = 0.04).

CONCLUSIONS

Among women who underwent MRI-guided breast biopsy, elevated BMI was associated with increased PPV and malignant biopsies. Patients with a higher BMI or Black or Hispanic race who had MRI-guided biopsy were less likely to be undergoing high-risk screening and more likely to have breast MRI to evaluate extent of known disease.

Diabetes, Obesity, and Inflammation: Impact on Clinical and Radiographic Features of Breast Cancer

Obesity, diabetes, and inflammation increase the risk of breast cancer, the most common malignancy in women. One of the mainstays of breast cancer treatment and improving outcomes is early detection through imaging-based screening. There may be a role for individualized imaging strategies for patients with certain co-morbidities. Herein, we review the literature regarding the accuracy of conventional imaging modalities in obese and diabetic women, the potential role of anti-inflammatory agents to improve detection, and the novel molecular imaging techniques that may have a role for breast cancer screening in these patients. We demonstrate that with conventional imaging modalities, increased sensitivity often comes with a loss of specificity, resulting in unnecessary biopsies and overtreatment. Obese women have body size limitations that impair image quality, and diabetes increases the risk for dense breast tis-sue. Increased density is known to obscure the diagnosis of cancer on routine screening mammography. Novel molecu-lar imaging agents with targets such as estrogen receptor, human epidermal growth factor receptor 2 (HER2), pyrimi-dine analogues, and ligand-targeted receptor probes, among others, have potential to reduce false positive results. They can also improve detection rates with increased resolution and inform therapeutic decision making. These emerg-ing imaging techniques promise to improve breast cancer diagnosis in obese patients with diabetes who have dense breasts, but more work is needed to validate their clinical application.

Fatores associados à realização de mamografia de acordo com dois critérios

Objetivo: objetivou-se comparar as prevalências e os fatores associados à realização de mamografia de acordo com dois critérios em vigência no Brasil.Métodos: estudo transversal, de base populacional, com mulheres entre 40 e 74 anos de Rio Grande, RS, Brasil. A cobertura de mamografia foi avaliada: 1) rastreamento anual para mulheres entre 40 e 74 anos; 2) rastreamento bienal para mulheres entre 50 e 69 anos. Os dados foram analisados por regressão de Poisson.Resultados: participaram do estudo 413 (critério 1) e 246 (critério 2) mulheres. A cobertura de mamografia pelo critério 1 foi de 49,4% (IC95% 43,8 a 55,0), oscilando de um quarto para as que não consultaram um médico no último ano até dois terços para aquelas com maior escolaridade. Segundo o critério 2, a cobertura foi de 65,5% (IC95% 59,2 a 71,7), indo de um terço entre as que não consultaram um médico no último ano a três quartos entre as obesas.Conclusões: a cobertura de mamografia diferiu conforme o critério empregado. Maior nível socioeconômico e ter consultado com médico no último ano foram os fatores mais associados, independentemente do critério.

Weight-lowering Effects of Glucagon-like Peptide-1 Receptor Agonists and Detection of Breast Cancer Among Obese Women with Diabetes

BACKGROUND

It has been proposed that the weight loss associated with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may improve detection of breast cancer in patients undergoing this treatment. We aimed to determine whether the weight-lowering effects of GLP-1 RAs are associated with an increased detection of breast cancer among obese women with type 2 diabetes.

METHODS

Using the UK Clinical Practice Research Datalink, we conducted a propensity score-matched cohort study among female obese patients with type 2 diabetes newly treated with antidiabetic drugs between 1 January 2007 and 31 January 2018. New users of GLP-1 RAs (n = 5,510) were matched to new users of second- to third-line noninsulin antidiabetic drugs (n = 5,510). We used time-dependent Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of breast cancer associated with different GLP-1 RA maximal weight loss categories (<5%, 5%-10%, >10%).

RESULTS

Breast cancer incidence gradually increased with GLP-1 RA maximal weight loss categories, with the highest HR observed for patients achieving at least 10% weight loss (HR = 1.8, 95% CI = 1.1, 2.8). In secondary analyses, the HR for >10% weight loss was highest in the 2-3 years since treatment initiation (HR = 2.9, 95% CI = 1.2, 6.9).

CONCLUSIONS

In this population-based study, the detection of breast cancer gradually increased with GLP-1 RA weight loss categories, particularly among those achieving >10% weight loss. These results are consistent with the hypothesis that substantial weight loss with GLP-1 RAs may improve detection of breast cancer among obese patients with type 2 diabetes.

Obesity and Breast Cancer: A Case of Inflamed Adipose Tissue

Obesity is associated with an increased risk of estrogen receptor-positive breast cancer in postmenopausal women and a worse prognosis for all major breast cancer subtypes regardless of menopausal status. While the link between obesity and the pathogenesis of breast cancer is clear, the molecular mechanism of this association is not completely understood due to the complexity of both obesity and breast cancer. The aim of this review is to highlight the association between obesity and breast cancer and discuss the literature, which indicates that this association is due to chronic adipose tissue inflammation. We will discuss the epidemiological data for the association between breast cancer incidence and progression as well as the potential molecular mechanisms for this association. We will focus on the role of inflammation within the adipose tissue during the pathogenesis of breast cancer. A better understanding of how obesity and adipose tissue inflammation affects the pathogenesis of breast cancer will lead to new strategies to reduce breast cancer risk and improve patient outcomes for obese patients.

Alcohol and Tobacco Use in Relation to Mammographic Density in 23,456 Women

BACKGROUND

Percent density (PD) is a strong risk factor for breast cancer that is potentially modifiable by lifestyle factors. PD is a composite of the dense (DA) and nondense (NDA) areas of a mammogram, representing predominantly fibroglandular or fatty tissues, respectively. Alcohol and tobacco use have been associated with increased breast cancer risk. However, their effects on mammographic density (MD) phenotypes are poorly understood.

METHODS

We examined associations of alcohol and tobacco use with PD, DA, and NDA in a population-based cohort of 23,456 women screened using full-field digital mammography machines manufactured by Hologic or General Electric. MD was measured using Cumulus. Machine-specific effects were estimated using linear regression, and combined using random effects meta-analysis.

RESULTS

Alcohol use was positively associated with PD (P trend = 0.01), unassociated with DA (P trend = 0.23), and inversely associated with NDA (P trend = 0.02) adjusting for age, body mass index, reproductive factors, physical activity, and family history of breast cancer. In contrast, tobacco use was inversely associated with PD (P trend = 0.0008), unassociated with DA (P trend = 0.93), and positively associated with NDA (P trend<0.0001). These trends were stronger in normal and overweight women than in obese women.

CONCLUSIONS

These findings suggest that associations of alcohol and tobacco use with PD result more from their associations with NDA than DA.

IMPACT

PD and NDA may mediate the association of alcohol drinking, but not tobacco smoking, with increased breast cancer risk. Further studies are needed to elucidate the modifiable lifestyle factors that influence breast tissue composition, and the important role of the fatty tissues on breast health.

Pattern of Mammography Utilization by Women Attending Asokoro District Hospital, Abuja, Nigeria

Introduction:

Mammography is a major tool for the screening and diagnosis of breast cancer globally. Poor funding and lack of good public health education for mammography in resource-limited countries limit access to mammographic services. In these settings, patients bear the cost of breast cancer screening from out-of-pocket expenses. The aim of this study was to interrogate the pattern of utilization of mammography by women of childbearing age, who attended Asokoro District Hospital (ADH) for Healthcare, with the view to increase uptake.

Materials and Methods:

This was a 4-year retrospective, cross-sectional study of 534 women who attended ADH from July 2015 to June 2019 for screening or diagnostic mammography. Data were extracted from completed questionnaire by women who had mammography during the period under review. The data were entered into Statistical Package for the Social Sciences version 27 by IBM for analysis.

Results:

The mean age of the women was 47.8 years ± 7.7 with a range of 30–82 years. Most of the women, 525 (94.9%), were referred for mammography by health workers; only nine (5.1%) had mammography on self-referral. In all, 71% of the women paid for their mammography from their pockets, whereas 28.1% made payments through the National Health Insurance Scheme (NHIS). A total of 100% of women who reported for mammography on self-referral paid for the services from their pockets. The association between the funding options and mode of referral was statistically significant, P = 0.049.

Conclusion:

This study showed that referral for mammography by health workers was responsible for not only most of the mammograms conducted but also all the women who utilized NHIS to pay for this service. Resources should therefore be directed towards creating awareness among health workers, especially with the present level of NHIS coverage in the population, in order to increase the uptake of screening mammography in the population.

Risk factors for ductal carcinoma in situ of the breast in the UK Biobank cohort study

Ductal carcinoma in situ of the breast (DCIS) is considered to be a non-obligate precursor of invasive breast cancer (IBC). This suggests that risk factors for DCIS should be a subset of those for IBC. To this end, we investigated whether demographic, lifestyle, and reproductive factors that have been linked to IBC risk are also associated with DCIS risk. This study was conducted in 263,788 women aged 40-69 years at enrolment into the UK Biobank population-based cohort. Information on demographic, reproductive and health factors was collected at baseline using computerized questionnaires, while incident DCIS was ascertained through linkage to UK cancer registries. Age-adjusted and multivariable hazard ratios were estimated using Cox proportional hazards models in the total sample and by menopausal status. During an average of 7 years of follow-up, 1,016 women developed DCIS. Multivariable analysis indicated that age, physical activity, height, family history of breast cancer, menopausal status, parity, and years between menarche and first live birth had associations with DCIS risk. Among post-menopausal women not using hormone replacement therapy, body mass index ≥30 kg/m² was associated with increased DCIS risk. This study, the largest to date including both pre-menopausal and post-menopausal women, confirms previous findings indicating correspondence between risk factors for DCIS and IBC and highlights the potential contribution to DCIS risk of anthropometric measures not previously reported to be associated with the disease, such as height and BMI amongst post-menopausal women.

The Impact of Obesity on Breast Cancer Diagnosis and Treatment

Purpose of Review

Obesity is a recognized risk factor for the development of breast cancer and recurrence even when patients are treated appropriately. We reviewed the literature that addresses the impact of obesity on diagnosis and the individual therapeutic interventions, and present a summary of the findings.

Recent Findings

Compared to non-obese women with breast cancer, obese women with breast cancer have a worse disease-free and overall survival despite appropriate local and systemic therapies. In brief, obese breast cancer patients experience more complications related to surgery, radiation, and chemotherapy. Further, obese patients are at increased risk for local recurrence compared to normal-weight women. Similarly, systemic chemotherapy is less effective, even when dosed appropriately on the basis of actual weight. Overall, endocrine therapy is less effective in obese women, and there is a suggestion that aromatase inhibitors may be selectively less effective than tamoxifen. Obese women are less likely to undergo breast reconstruction than normal-weight women, and those who do have surgery experience more surgical complications.

Summary

The efficacy of cancer treatments is significantly lower in obese breast cancer survivors, posing greater challenges in patient care and disease management in this patient population. Further investigations are warranted to assess the effects on treatment outcomes and optimize therapeutic mechanisms in order to successfully target breast cancer associated with obesity.

Causal effect of obesity on gynecologic malignancies

INTRODUCTION

Gynecologic malignancies are estimated to affect 110,070 women and will be the cause of death in approximately 32,120 in 2018. Endometrial cancer is among the most prevalent with 63,320 estimated new cases and approximately 11,350 deaths, followed by ovarian cancer with an estimate of 22,000 new cases and 14,000 deaths annually. Obesity is one of the most modifiable risk factors. Providers should engage in a multifaceted approach to patient education and healthcare to decrease the projected cases of obesity-related cancers.

BACKGROUND

The literature demonstrates a significant link between obesity and the development of certain malignancies such as endometrial, pancreatic, and renal cancer. Specific mechanisms found to play a role in the development of these malignancies include alterations of the metabolic pathway attributed to lipid accumulation as well as a chronic inflammatory process. Obesity also predisposes patients to other medical comorbidities as well as a poorer prognosis once a diagnosis of cancer is established. Factors contributing to poorer prognosis include challenges with treatment planning, specifically pertaining to inappropriate chemotherapy dosing and delivery of radiation therapy. Surgical approach and perioperative management are similarly challenging in obese patients and are associated with increased risk of complications.

CONCLUSION

Obesity is a modifiable factor which is associated with an increased risk of cancer and poorer outcomes. Providers should educate patients on all health hazards of obesity, including increased risk of cancer, and encourage them to participate in a structured weight loss plan.

Breast pathology and mammography BI-RADS category correlation study - A single institute experience

Although recent technological advances, there is still discordance between mammography findings and pathologic diagnoses, especially for certain racial/ethnic populations. In this study we correlated the mammography BI-RADS categories with pathologic diagnoses, aiming to evaluate the performance of mammography in breast cancer detection in a unique poor population consisting of mostly Hispanics and African Americans. A total of 3935 female patients with a breast mammography and a subsequent breast pathology report within 90 days were retrospectively analyzed. There were 875 (22.2%) patients with a negative or probably benign mammography (BI-RADS 1, 2 and 3), and 33 (3.8%) of them had a malignant pathologic diagnosis. Patients with malignant pathologic diagnoses were older, higher in socioeconomic status (SES), and more likely to be African American or White, compared to those with non-malignant pathologic findings. They mostly presented with related symptoms (e.g. breast pain, mass or discharge) and/or family history or past history of breast cancers, which triggered secondary imaging examination and subsequent breast biopsy/excision, and eventually resulted to the diagnosis of breast cancers. In conclusion, our studies indicated that the performance of mammography is comparable in detection of breast cancers among Hispanics, African American and White populations, if it was done in the same facility. Our results also suggested that for patients with presenting symptoms, past history of breast cancer or strong family history of breast cancer, a secondary breast imaging examination may be warranted following a negative to probably benign mammography (BI-RADS 1-3).

Technical challenges of imaging & image-guided interventions in obese patients

Obese patients challenge imaging departments in their ability to obtain diagnostic quality images and to perform image-guided interventions. These technical challenges include properly accommodating large patients on imaging equipment, adjusting equipment settings to address imaging limitations, and pre-planning and preparation for image-guided interventions to insure safe and successful outcomes. Knowing and addressing these challenges can result in successfully addressing the imaging and image-guided interventions needs of obese patients.

Patient and physician characteristics affect adherence to screening mammography: A population-based cohort study

BACKGROUND

Screening mammograms are widely recommended biennially for women between the ages of 50 and 74. Despite the benefits of screening mammograms, full adherence to recommendations falls below 75% in most developed countries. Many studies have identified individual (obesity, smoking, socio-economic status, and co-morbid conditions) and primary-care physician parameters (physician age, gender, clinic size and cost) that influence adherence, but little data exists from large population studies regarding the interaction of these individual factors.

METHODS

We performed a historical cohort study of 44,318 Israeli women age 56-74 using data captured from electronic medical records of a large Israeli health maintenance organization. Univariate analysis was used to examine the association between each factor and adherence (none, partial or full) with screening recommendations between 2008-2014. Multivariate analysis was used to examine the significance of these factors in combination, using binary and multinomial logistic regression.

RESULTS

Among 44,318 women, 42%, 43% and 15% were fully, partially and non-adherent to screening recommendations, respectively. Factors associated with inferior adherence identified in our population included: smoking, obesity, low body weight, low socio-economic status, depression, diabetes mellitus and infrequent physician visits, while, women with ischemic heart disease, female physicians, physicians between the ages of 40 and 60, and medium-sized clinics were associated with higher screening rates. Most factors remained significant in the multivariate analysis.

CONCLUSIONS

Both individual and primary-care physician factors contribute to adherence to mammography screening guidelines. Strategies to improve adherence and address disparities in mammography utilization will need to address these factors.

Errors in Mammography Cannot be Solved Through Technology Alone

Mammography has been the frontline screening tool for breast cancer for decades. However, high error rates in the form of false negatives (FNs) and false positives (FPs) have persisted despite technological improvements. Radiologists still miss between 10% and 30% of cancers while 80% of woman recalled for additional views have normal outcomes, with 40% of biopsied lesions being benign. Research show that the majority of cancers missed is actually visible and looked at, but either go unnoticed or are deemed to be benign. Causal agents for these errors include human related characteristics resulting in contributory search, perception and decision-making behaviours. Technical, patient and lesion factors are also important relating to positioning, compression, patient size, breast density and presence of breast implants as well as the nature and subtype of the cancer itself, where features such as architectural distortion and triple-negative cancers remain challenging to detect on screening. A better understanding of these causal agents as well as the adoption of technological and educational interventions, which audits reader performance and provide immediate perceptual feedback, should help. This paper reviews the current status of our knowledge around error rates in mammography and explores the factors impacting it. It also presents potential solutions for maximizing diagnostic efficacy thus benefiting the millions of women who undergo this procedure each year.

Validity and reliability of self-reported health indicators among women attending organized mammographic screening

AIMS

Risk factors for breast cancer are often used for adjustment in epidemiological studies, including in the evaluation of early performance measures in mammographic screening. Information about risk factors among participants in the Norwegian Breast Cancer Screening Program has been collected since 2006. We aimed to examine the validity of self-reported history of breast cancer and mammographic screening, as well as the reliability of weight and height amongt women attending the program.

METHODS

Information from a questionnaire handed in by participants in the program, 2006-2015, was linked to outcomes from the Cancer Registry of Norway. Sensitivity, specificity, and positive predictive values (PPV) were calculated for self-reported histories of breast cancer and screening. Results were stratified by five-year age groups and evaluated using the χ² statistic. The reliability of self-reported weight and height were assessed using descriptive statistics, histograms, and mean differences.

RESULTS

A total of 538,907 of 611,711 (88%) women attending the program during the study period returned at least one part of the questionnaire. The overall sensitivity, specificity, and PPV for breast cancer and mammography were 96.5%, 99.8%, and 81.3%; and 99.9%, 84.4%, and 97.6% respectively. The mean difference in self-reported weight was 0.35 kg and for height was -0.14 cm, over a period of up to 10 years.

CONCLUSIONS

Norwegian women attending the screening program are reasonably accurate in self-reporting their breast cancer and mammography histories. On average, women consistently reported weight and height within one kg/cm.

[Outcomes of patients with breast cancer in function of their body mass index]

OBJECTIVE

The aim of this study was to evaluate outcomes of patients with breast cancer in function of the body mass index (BMI).

METHODS

The study cohort consisted of consecutive women undergoing surgery for breast cancer in our institution between January 2009, and September 2013. Individual records of all patients were reviewed and analyzed. Patient BMI was categorized as underweight, normal, overweight and obese.

RESULTS

A total of 1599 patients were evaluated. Patients were followed for one to 265months with a mean of 36.4months. The number of patients in each of the BMI categories was 66, 779, 463 and 291 for underweight, normal, overweight and obese women respectively. Women with higher BMI were more frequently affected by hypertension (18, 21, 35 and 47% respectively, P<0.0001) and diabetes (3, 2, 7 and 7% respectively, P<0.0001). Obese women had more frequently an inflammatory presentation (P=0.006), larger tumour size (P=0.038) and axillary lymph node involvement (P=0.03) with much more positive lymph nodes (P=0.02). Patients had the same protocols of treatment (surgery and adjuvant treatment). There was no statistically significant difference in overall 5-years survival between groups (P=0.30).

CONCLUSIONS

Our study demonstrate a more aggressive clinical and histological presentation for obese women with breast cancer.

Body weight and sensitivity of screening mammography

AIM

Obese women tend to participate less in breast cancer screening than normal weight women. However, obese women have fattier breast than normal weight women, and screening mammography works better in fatty than in dense breasts. One might, therefore, hypothesise that obese women would actually benefit more from screening than other women.

METHODS

We combined data from the Danish Diet, Cancer and Health study and the organised population-based screening mammography programme in Copenhagen, Denmark. Women were categorised according to body mass index (BMI) (<20; 20 to <25; 25 to <30; 30 to <35, and 35+). We measured recall rate, sensitivity and specificity for subsequent screens with a 2-year follow-up period.

RESULTS

The study included 6787 women. The recall rate varied from 1.4% for women with BMI <20 to 1.9% for women with BMI 35+, test for trend p = 0.86. Sensitivity varied from 42% (95% confidence interval [CI] 20-64%) for women with BMI <20 to 100% (95% CI 69-100%) for women with BMI 35+, test for trend p = 0.015. Specificity was fairly constant across BMI levels, being on average 98.8%, test for trend p = 0.79.

CONCLUSION

This study showed that obese women were the ones with the highest sensitivity of screening mammography, while the specificity of screening remained stable across weight groups. Screening programmes should be organized to encourage these women to overcome obstacles for participation.

Radiation-Induced Breast Cancer Incidence and Mortality From Digital Mammography Screening: A Modeling Study

BACKGROUND

Estimates of risk for radiation-induced breast cancer from mammography screening have not considered variation in dose exposure or diagnostic work-up after abnormal screening results.

OBJECTIVE

To estimate distributions of radiation-induced breast cancer incidence and mortality from digital mammography screening while considering exposure from screening and diagnostic mammography and dose variation among women.

DESIGN

2 simulation-modeling approaches.

SETTING

U.S. population.

PATIENTS

Women aged 40 to 74 years.

INTERVENTION

Annual or biennial digital mammography screening from age 40, 45, or 50 years until age 74 years.

MEASUREMENTS

Lifetime breast cancer deaths averted (benefits) and radiation-induced breast cancer incidence and mortality (harms) per 100,000 women screened.

RESULTS

Annual screening of 100,000 women aged 40 to 74 years was projected to induce 125 breast cancer cases (95% CI, 88 to 178) leading to 16 deaths (CI, 11 to 23), relative to 968 breast cancer deaths averted by early detection from screening. Women exposed at the 95th percentile were projected to develop 246 cases of radiation-induced breast cancer leading to 32 deaths per 100,000 women. Women with large breasts requiring extra views for complete examination (8% of population) were projected to have greater radiation-induced breast cancer risk (266 cancer cases and 35 deaths per 100,000 women) than other women (113 cancer cases and 15 deaths per 100,000 women). Biennial screening starting at age 50 years reduced risk for radiation-induced cancer 5-fold.

LIMITATION

Life-years lost from radiation-induced breast cancer could not be estimated.

CONCLUSION

Radiation-induced breast cancer incidence and mortality from digital mammography screening are affected by dose variability from screening, resultant diagnostic work-up, initiation age, and screening frequency. Women with large breasts may have a greater risk for radiation-induced breast cancer.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force, National Cancer Institute.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A perfect storm: How tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change

It is well known that there is a significant racial divide in breast cancer incidence and mortality rates. African American women are less likely to be diagnosed with breast cancer than white women but are more likely to die from it. This review explores the factors that may contribute to the racial survival disparity. Consideration is paid to what is known about the role of differences in tumor biology, genomics, cancer screening, and quality of cancer care. It is argued that it is the collision of 2 forces, tumor biology and genomics, with patterns of care that leads to the breast cancer mortality gap. The delays, misuse, and underuse of treatment for African American patients are of increased significance when these patients are presenting with more aggressive forms of breast cancer. In the current climate of health care reform ushered in by the Affordable Care Act, this article also evaluates interventions to close the disparity gap. Prior interventions have been too narrowly focused on the patient rather than addressing the system and improving care across the continuum of breast cancer evaluation and treatment. Lastly, areas of future investigation and policy initiatives aimed at reducing the racial survival disparity in breast cancer are discussed.

Impact of mammography screening interval on breast cancer diagnosis by menopausal status and BMI

BACKGROUND

Controversy remains regarding the frequency of screening mammography. Women with different risks for developing breast cancer because of body mass index (BMI) may benefit from tailored recommendations.

OBJECTIVE

To determine the impact of mammography screening interval for women who are normal weight (BMI < 25), overweight (BMI 25-29.9), or obese (BMI ≥ 30), stratified by menopausal status.

DESIGN

Two cohorts selected from the Breast Cancer Surveillance Consortium. Patient and mammography data were linked to pathology databases and tumor registries.

PARTICIPANTS

The cohort included 4,432 women aged 40-74 with breast cancer; the false-positive analysis included a cohort of 553,343 women aged 40-74 without breast cancer.

MAIN MEASURES

Stage, tumor size and lymph node status by BMI and screening interval (biennial vs. annual). Cumulative probability of false-positive recall or biopsy by BMI and screening interval. Analyses were stratified by menopausal status.

KEY RESULTS

Premenopausal obese women undergoing biennial screening had a non-significantly increased odds of a tumor size > 20 mm relative to annual screeners (odds ratio [OR] = 2.07; 95 % confidence interval [CI] 0.997 to 4.30). Across all BMI categories from normal to obese, postmenopausal women with breast cancer did not present with higher stage, larger tumor size or node positive tumors if they received biennial rather than annual screening. False-positive recall and biopsy recommendations were more common among annually screened women.

CONCLUSION

The only negative outcome identified for biennial vs. annual screening was a larger tumor size (> 20 mm) among obese premenopausal women. Since annual mammography does not improve stage at diagnosis compared to biennial screening and false-positive recall/biopsy rates are higher with annual screening, women and their primary care providers should weigh the harms and benefits when deciding on annual versus biennial screening.

Body mass index (BMI) and breast cancer: impact on tumor histopathologic features, cancer subtypes and recurrence rate in pre and postmenopausal women

The study aims to analyze the association between body mass index (BMI) at time of diagnosis, breast cancer histopathologic features (tumor size, nuclear grade, estrogen and progesterone receptor (ER and PgR) and HER-2/neu expression, histological subtypes, Ki-67 index, lymphatic/vascular invasion, axillary nodes involvement) and incidence of different subtypes defined using hormone receptors and HER2/neu expression, according to menopausal status; to evaluate the impact of BMI on disease free survival (DFS) at multivariate analysis. A total of 2148 patients (592 premenopausal, 1556 postmenopausal) were classified into subgroups according to BMI distribution. High BMI was significantly associated with larger size tumor both in pre (p = 0.01) and postmenopausal women (p = 0.00). Obese premenopausal women showed worse histopathologic features (more metastatic axillary lymphnodes, p = 0.017 and presence of vascular invasion, p = 0.006) compared to under/normal weight group. Postmenopausal patients with BMI > 25 developed more frequently ER/PgR positive cancers (87% versus 75%, p 0.017), while no association was found in premenopausal women. We could not found any statistically significant correlation between breast cancer subtypes (luminal A, B, HER-2 and basal-like) and BMI both in pre and postmenopause. Higher BMI was significantly associated with a shorter DR-FS in postmenopausal women but the independent prognostic role of obesity was not confirmed in our analysis.

Body Mass Index and Abdominal Ultrasound Image Quality

The objective was to assess the consensus among sonographers that the quality of abdominal ultrasound (US) images is related to the patient’s body mass index (BMI). Fourteen sonographers completed a 12-item questionnaire to evaluate their experience with abdominal US imaging with respect to image quality in correlation with the patient’s adipose tissue. Of the sonographers sampled, 85.7% agreed that there is an association between the amount of adipose tissue on a patient’s abdomen and the quality of US image obtained; 85.7% also agreed that a normal BMI of 18.5 to 24.9 provides the best US image. However, only 28.6% agreed that normal amounts of adipose tissue produce poor image quality. There appears to be agreement among sonographers that BMI is a factor in obtaining good quality abdominal US images. The general consensus was that the best abdominal US images were obtained in patients with normal BMI, whereas images obtained from patients with BMI 30.0 to 34.9 and to a lesser extent BMI 25.0 to 29.9 were limited in quality.

Variation in tumor natural history contributes to racial disparities in breast cancer stage at diagnosis

Black women tend to be diagnosed with breast cancer at a more advanced stage than whites and subsequently experience elevated breast cancer mortality. We sought to determine whether there are racial differences in tumor natural history that contribute to these disparities. We used the University of Wisconsin Breast Cancer Simulation Model, a validated member of the National Cancer Institute's Cancer Intervention and Surveillance Modeling Network, to evaluate the contribution of racial differences in tumor natural history to observed disparities in breast cancer incidence. We fit eight natural history parameters in race-specific models by calibrating to the observed race- and stage-specific 1975-2000 U.S. incidence rates, while accounting for known racial variation in population structure, underlying risk of breast cancer, screening mammography utilization, and mortality from other causes. The best fit models indicated that a number of natural history parameters must vary between blacks and whites to reproduce the observed stage-specific incidence patterns. The mean of the tumor growth rate parameter was 63.6 % higher for blacks than whites (0.18, SE 0.04 vs. 0.11, SE 0.02). The fraction of tumors considered highly aggressive based on their tendency to metastasize at a small size was 2.2 times greater among blacks than whites (0.41, SE 0.009 vs. 0.019, SE 0.008). Based on our simulation model, breast tumors in blacks grow faster and are more likely to metastasize earlier than tumors in whites. These differences suggest that targeted prevention and detection strategies that go beyond equalizing access to mammography may be needed to eliminate breast cancer disparities.

Body mass index, tumor characteristics, and prognosis following diagnosis of early-stage breast cancer in a mammographically screened population

PURPOSE

Many studies suggest increased body mass index (BMI) is associated with worse breast cancer outcomes, but few account for variability in screening, access to treatment, and tumor differences. We examined the association between BMI and risk of breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality, and evaluated whether tumor characteristics differ by BMI among a mammographically screened population with access to treatment.

METHODS

Using a retrospective cohort study design, we followed 485 women aged ≥40 years diagnosed with stage I/II breast cancer within 24 months of a screening mammogram occurring between 1988 and 1993 for 10-year outcomes. BMI before diagnosis was categorized as normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). Tumor marker expression was assessed via immunohistochemistry using tissue collected before adjuvant treatment. Medical records were abstracted to identify treatment, recurrence, and mortality. We used Cox proportional hazards to separately model the hazard ratios (HR) of our three outcomes by BMI while adjusting for age, stage, and tamoxifen use.

RESULTS

Relative to normal-weight women, obese women experienced increased risk of recurrence (HR 2.43; 95 % CI 1.34-4.41) and breast cancer death (HR 2.41; 95 % CI 1.00-5.81) within 10 years of diagnosis. There was no association between BMI and all-cause mortality. Obese women had significantly faster growing tumors, as measured by Ki-67.

CONCLUSIONS

Our findings add to the growing evidence that obesity may contribute to poorer breast cancer outcomes, and also suggest that increased tumor proliferation among obese women is a pathway that explains part of their excess risk of adverse outcomes.

The impact of obesity on follow-up after an abnormal screening mammogram

BACKGROUND

Effective breast cancer screening and early detection are crucial for obese women, who experience a higher incidence of the disease and present at later stages.

METHODS

We examined the association between body mass index (BMI) and timeliness of follow-up after 241,222 abnormal screening mammograms carried out on 201,470 women in the Breast Cancer Surveillance Consortium. Each mammogram had one of three recommendations for follow-up: short-interval follow-up, immediate additional diagnostic imaging, and biopsy/surgical consultation. We used logistic regression to estimate the adjusted effect of BMI on any recorded follow-up within 270 days of the recommendation; linear regression was used to model the mean follow-up time among those with recorded follow-up.

RESULTS

As compared with normal-weight women, higher BMI was associated with slightly increased odds of follow-up among women who received a recommendation for short-interval follow-up (ORs: 1.03-1.10; P = 0.04) or immediate additional imaging (ORs: 1.03-1.09; P = 0.01). No association was found for biopsy/surgical consultation recommendations (P = 0.90). Among those with recorded follow-up, higher BMI was associated with longer mean time to follow-up for both short-interval (3-10 days; P < 0.001) and additional imaging recommendations (2-3 days; P < 0.001) but not biopsy/surgical consultation (P = 0.06). Regardless of statistical significance, actual differences in days to follow-up across BMI groups were small and unlikely to be clinically significant.

CONCLUSIONS

Once obese women access screening mammography, their follow-up after abnormal results is similar to that of normal-weight women.

IMPACT

Efforts to improve early detection of breast cancer in obese women should focus elsewhere, such as improving participation in screening mammography.

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

OBJECTIVE

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

Outcome of mammography in women with large breasts

Mammography has been established as an effective screening tool for the early detection of breast cancer. Obesity may lead to increased breast size and has been linked to increased rates of breast cancer. As women with larger breasts may be predisposed to developing cancer, it is important that mammography is an appropriate test in these women. This study investigated the sensitivity and specificity of mammography in women with larger breasts in a population screening program.

METHOD

Data was obtained from 848,648 eligible screening episodes of women aged over 40. Of these episodes, 758,860 were eligible for the study, with 7.2% (54,879 screens) deemed to have large breasts. Large breasts were defined as those for whom at least one large cassette was used in the mammographic process. Those women having only four standard cassettes per screen were classified as having average size breasts (703,981 screens, 92.8%). Cancer detection rates, interval cancer rates (false negatives) and recall to assessment rates were compared for women examined on standard sized cassettes versus large cassettes. Chance corrected measures of sensitivity and specificity and 95% confidence intervals (CI) were calculated for women with and without large breasts.

RESULTS

The study found that the sensitivity and specificity of mammography was greater for larger breasted woman. The incidence of breast cancer was also found to be higher in woman with larger breasts in the combined population (73.1 per 100,000 (95% CI 65.9-80.2) in large breasted women versus 52.8 (95% CI 51.1-54.5) in other women) and in each of the specific age groups. This study confirms the appropriateness of mammographic screening for women with large breasts.

Bodyweight and other correlates of symptom-detected breast cancers in a population offered screening

OBJECTIVE

To determine the factors associated with symptom-detected breast cancers in a population offered screening.

METHODS

We interviewed 1,459 Australian women aged 40-69, 946 with symptom-detected and 513 with mammogram-detected invasive breast cancers ≥ 1.1 cm in diameter about their personal, mammogram, and breast histories before diagnosis and reviewed medical records for tumor characteristics and mammogram dates, calculating ORs and 95% confidence intervals (CIs) for symptom- versus mammogram-detected cancers in logistic regression models.

RESULTS

Lack of regular mammograms (<2 mammograms in the 4.5 years before diagnosis) was the strongest correlate of symptom-detected breast cancer (OR = 3.04 for irregular or no mammograms). In women who had regular mammograms (≥ 2 mammograms in the 4.5 years before diagnosis), the independent correlates of symptom-detected cancers were low BMI (OR < 25 kg/m(2) vs. ≥ 30 kg/m(2) = 2.18, 95% CI 1.23-3.84; p = 0.008), increased breast density (available in 498 women) (OR highest quarter vs. lowest = 3.50, 95% CI 1.76-6.97; p (trend) = 0.004), high-grade cancer, and a larger cancer (each p < 0.01). In women who did not have regular mammograms, the independent correlates were age <50 years, a first cancer, and a ≥ 2-cm cancer. Smoking appeared to modify the association of symptom-detected cancer with low BMI (higher ORs for low BMI in current smokers) and estrogen receptor (ER) status (higher ORs for low BMI in ER cancers).

CONCLUSION

Women with low BMI may benefit from a tailored approach to breast cancer detection, particularly if they smoke.

Feasibility and satisfaction with a tailored web-based audit intervention for recalibrating radiologists' thresholds for conducting additional work-up

RATIONALE AND OBJECTIVES

To examine the feasibility of and satisfaction with a tailored web-based intervention designed to decrease radiologists' recommendation of inappropriate additional work-up after a screening mammogram.

MATERIALS AND METHODS

We developed a web-based educational intervention designed to reduce inappropriate recall. Radiologists were randomly assigned to participate in an early intervention group or a late (control) intervention group, the latter of which served as a control for a 9-month follow-up period, after which they were invited to participate in the intervention. Intervention content was derived from our prior research and included three modules: 1) an introduction to audit statistics for mammography performance; 2) a review of data showing radiologists' inflated perceptions of medical malpractice risks related to breast imaging, and 3) a review of data on breast cancer risk among women seen in their practices. Embedded within the intervention were individualized audit data for each participating radiologists obtained from the national Breast Cancer Surveillance Consortium.

RESULTS

Seventy-four radiologists (37.8%; 74/196) consented to the intervention, which was completed by 67.5% (27/40) of those randomized to the early intervention group and 41.2% (14/34) of those randomized to the late (control) group. Thus, a total of 41 (55%) completed the intervention. On average, three log-ins were used to complete the program (range 1-14), which took approximately 1 hour. Ninety-five percent found the program moderately to very helpful in understanding how to calculate basic performance measures. Ninety-three percent found viewing their own performance measures moderately to very helpful, and 83% reported it being moderately to very important to learn that the breast cancer risk in their screening population program was lower than perceived. The percentage of radiologists who reported that the risk of medical malpractice influences their recall rates dropped from 36.3% preintervention to 17.8% after intervention with a similar drop in perceived influence of malpractice risk on their recommendations for breast biopsy (36.4 to 17.3%). More than 75% of radiologists answered the postintervention knowledge questions correctly, and the percent of time spent in breast imaging did not appear to influence responses. The majority (>92%) of participants correctly responded that the target recall rate in the United States is 9%. The mean self-reported recall rates were 13.0 for radiologists spending <40% time in breast imaging and 14.9% for those spending >40% time spent in breast imaging, which was highly correlated with their actual recall rates (0.991; P < .001).

CONCLUSIONS

Radiologists who begin an internet-based tailored intervention designed to help reduce unnecessary recall will likely complete it, although only 55% who consented to the study actually undertook the intervention. Participants found the program useful in helping them understand why their recall rates may be elevated.

Race-specific impact of natural history, mammography screening, and adjuvant treatment on breast cancer mortality rates in the United States

BACKGROUND

U.S. Black women have higher breast cancer mortality rates than White women despite lower incidence. The aim of this study is to investigate how much of the mortality disparity can be attributed to racial differences in natural history, uptake of mammography screening, and use of adjuvant therapy.

METHODS

Two simulation models use common national race, and age-specific data for incidence, screening and treatment dissemination, stage distributions, survival, and competing mortality from 1975 to 2010. Treatment effectiveness and mammography sensitivity are assumed to be the same for both races. We sequentially substituted Black parameters into the White model to identify parameters that drive the higher mortality for Black women in the current time period.

RESULTS

Both models accurately reproduced observed breast cancer incidence, stage and tumor size distributions, and breast cancer mortality for White women. The higher mortality for Black women could be attributed to differences in natural history parameters (26-44%), use of adjuvant therapy (11-19%), and uptake of mammography screening (7-8%), leaving 38% to 46% unexplained.

CONCLUSION

Black women appear to have benefited less from cancer control advances than White women, with a greater race-related gap in the use of adjuvant therapy than screening. However, a greater portion of the disparity in mortality appears to be due to differences in natural history and undetermined factors.

IMPACT

Breast cancer mortality may be reduced substantially by ensuring that Black women receive equal adjuvant treatment and screening as White women. More research on racial variation in breast cancer biology and treatment utilization is needed.

The impact of obesity on gynecologic cancer screening: an integrative literature review

INTRODUCTION

Evidence indicates lower rates of breast and cervical cancer screening among obese compared to nonobese women. This integrative review examines the association between gynecologic cancer screening and body weight, as well as potential barriers to screening.

METHODS

A literature search of standard computerized databases was conducted for peer-reviewed articles published between 1950 and January 2009.

RESULTS

Twenty-three studies met the criteria for review. Of the 17 studies that evaluated rates of cervical cancer screening, 13 found obese women significantly less likely than their nonobese counterparts to have had a recent Papanicolaou test, a trend that was stronger in white women when compared to African American women. Eight of the 15 studies examining routine mammography found an inverse association between increasing body weight and recent screening, although findings generally pertained only to women who were white and/or severely obese. Possible barriers to care included embarrassment and perceived weight stigma in the clinical setting, lack of appropriately sized examination equipment, and poor patient-provider communication.

DISCUSSION

Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women.