More than a Half Century of Misinformation About Breast Cancer Screening

The following is an overview of the numerous efforts to reduce access for women to breast cancer screening. Misinformation has been promoted over the many years to suggest that screening only works for women aged 50 years and over. In fact, there are no, scientifically derived data, to support the use of the age of 50 years as a threshold for screening. The randomized, controlled trials have proved that screening saves lives for women aged 40 to 74 years (the age of the women who participated).

Screening mammography performance according to breast density: a comparison between radiologists versus standalone intelligence detection

BACKGROUND

Artificial intelligence (AI) algorithms for the independent assessment of screening mammograms have not been well established in a large screening cohort of Asian women. We compared the performance of screening digital mammography considering breast density, between radiologists and AI standalone detection among Korean women.

METHODS

We retrospectively included 89,855 Korean women who underwent their initial screening digital mammography from 2009 to 2020. Breast cancer within 12 months of the screening mammography was the reference standard, according to the National Cancer Registry. Lunit software was used to determine the probability of malignancy scores, with a cutoff of 10% for breast cancer detection. The AI's performance was compared with that of the final Breast Imaging Reporting and Data System category, as recorded by breast radiologists. Breast density was classified into four categories (A-D) based on the radiologist and AI-based assessments. The performance metrics (cancer detection rate [CDR], sensitivity, specificity, positive predictive value [PPV], recall rate, and area under the receiver operating characteristic curve [AUC]) were compared across breast density categories.

RESULTS

Mean participant age was 43.5 ± 8.7 years; 143 breast cancer cases were identified within 12 months. The CDRs (1.1/1000 examination) and sensitivity values showed no significant differences between radiologist and AI-based results (69.9% [95% confidence interval [CI], 61.7-77.3] vs. 67.1% [95% CI, 58.8-74.8]). However, the AI algorithm showed better specificity (93.0% [95% CI, 92.9-93.2] vs. 77.6% [95% CI, 61.7-77.9]), PPV (1.5% [95% CI, 1.2-1.9] vs. 0.5% [95% CI, 0.4-0.6]), recall rate (7.1% [95% CI, 6.9-7.2] vs. 22.5% [95% CI, 22.2-22.7]), and AUC values (0.8 [95% CI, 0.76-0.84] vs. 0.74 [95% CI, 0.7-0.78]) (all P < 0.05). Radiologist and AI-based results showed the best performance in the non-dense category; the CDR and sensitivity were higher for radiologists in the heterogeneously dense category (P = 0.059). However, the specificity, PPV, and recall rate consistently favored AI-based results across all categories, including the extremely dense category.

CONCLUSIONS

AI-based software showed slightly lower sensitivity, although the difference was not statistically significant. However, it outperformed radiologists in recall rate, specificity, PPV, and AUC, with disparities most prominent in extremely dense breast tissue.

Mammography Screening Should Begin at Age 40 Years

The 2023 U.S. Preventive Services Task Force draft recommendation statement on screening for breast cancer recommends lowering the starting age for biennial screening with mammography to age 40 years from 50 years, the age of screening initiation that the Task Force had previously recommended since 2009. A recent Perspective article in the New England Journal of Medicine by Woloshin et al contends that this change will provide no additional benefit and is unjustified. This article reviews the main ideas presented by Woloshin et al and provides substantial evidence not considered by those authors in support of screening mammography in U.S. women starting at age 40 years.

Mammography-based deep learning model for coronary artery calcification

AIMS

Mammography, commonly used for breast cancer screening in women, can also predict cardiovascular disease. We developed mammography-based deep learning models for predicting coronary artery calcium (CAC) scores, an established predictor of coronary events.

METHODS AND RESULTS

We evaluated a subset of Korean adults who underwent image mammography and CAC computed tomography and randomly selected approximately 80% of the participants as the training dataset, used to develop a convolutional neural network (CNN) to predict detectable CAC. The sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), and overall accuracy of the model's performance were evaluated. The training and validation datasets included 5235 and 1208 women, respectively [mean age, 52.6 (±10.2) years], including non-zero cases (46.8%). The CNN-based deep learning prediction model based on the Resnet18 model showed the best performance. The model was further improved using contrastive learning strategies based on positive and negative samples: sensitivity, 0.764 (95% CI, 0.667-0.830); specificity, 0.652 (95% CI, 0.614-0.710); AUROC, 0.761 (95% CI, 0.742-0.780); and accuracy, 70.8% (95% CI, 68.8-72.4). Moreover, including age and menopausal status in the model further improved its performance (AUROC, 0.776; 95% CI, 0.762-0.790). The Framingham risk score yielded an AUROC of 0.736 (95% CI, 0.712-0.761).

CONCLUSION

Mammography-based deep learning models showed promising results for predicting CAC, performing comparably to conventional risk models. This indicates mammography's potential for dual-risk assessment in breast cancer and cardiovascular disease. Further research is necessary to validate these findings in diverse populations, with a particular focus on representation from national breast screening programmes.

Health benefits and harms of mammography screening in older women (75+ years)-a systematic review

BACKGROUND

There is little evidence on the balance between potential benefits and harms of mammography screening in women 75 years and older. The aim of this systematic review was to synthesise the evidence on the outcomes of mammography screening in women aged 75 years and older.

METHODS

A systematic review of mammography screening studies in women aged 75 years and over.

RESULTS

Thirty-six studies were included in this review: 27 observational studies and 9 modelling studies. Many of the included studies used no or uninformative comparison groups resulting in a potential bias towards the benefits of screening. Despite this, there was mixed evidence about the benefits and harms of continuing mammography screening beyond the age of 75 years. Some studies showed a beneficial effect on breast cancer mortality, and other studies showed no effect on mortality. Some studies showed some harms (false positive tests and recalls) being comparable to those in younger age-groups, with other studies showing increase in false positive screens and biopsies in older age-group. Although reported in fewer studies, there was consistent evidence of increased overdiagnosis in older age-groups.

CONCLUSION

There is limited evidence available to make a recommendation for/against continuing breast screening beyond the age of 75 years. Future studies should use more informative comparisons and should estimate overdiagnosis given potentially substantial harm in this age-group due to competing causes of death. This review was prospectively registered with PROSPERO (CRD42020203131).

Outcomes of Breast Cancer Screening Strategies Based on Cancer Intervention and Surveillance Modeling Network Estimates

Background There is ongoing debate about recommendations for breast cancer screening strategies, specifically regarding the frequency of screening and the age at which to initiate screening. Purpose To compare estimates of breast cancer screening outcomes published by the Cancer Intervention and Surveillance Modeling Network (CISNET) to understand the benefits and risks of different screening scenarios. Materials and Methods Modeling estimates published by CISNET are based on hypothetical cohorts in the United States and compare women, starting at 40 years of age, who do and do not undergo breast cancer screening with mammography. The four scenarios assessed in this study, of multiple possible scenarios, were biennial screening ages 50-74 years (2009 and 2016 U.S. Preventive Services Task Force [USPSTF] recommendations), biennial screening ages 40-74 years (2023 USPSTF draft recommendation), annual screening ages 40-74 years, and annual screening ages 40-79 years. For each scenario, CISNET estimates of median lifetime benefits were compared. Risks that included false-positive screening results per examination and benign biopsies per examination were also calculated and compared. Results Estimates from CISNET 2023 showed that annual screening ages 40-79 years improved breast cancer mortality reduction compared with biennial screening ages 50-74 years and biennial screening ages 40-74 years (41.7%, 25.4%, and 30%, respectively). Annual screening ages 40-79 years averted the most breast cancer deaths (11.5 per 1000) and gained the most life-years (230 per 1000) compared with other screening scenarios (range, 6.7-11.5 per 1000 and 121-230 per 1000, respectively). False-positive screening results per examination were less than 10% for all screening scenarios (range, 6.5%-9.6%) and lowest for annual screening ages 40-79 years (6.5%). Benign biopsies per examination were less than 1.33% for all screening scenarios (range, 0.88%-1.32%) and lowest for annual screening ages 40-79 years (0.88%). Conclusion CISNET 2023 modeling estimates indicate that annual breast cancer screening starting at 40 years of age provides the greatest benefit to women and the least risk per examination. © RSNA, 2024 See also the editorial by Joe in this issue.

The Impact of Virtual Reality on Anxiety and Pain During US-Guided Breast Biopsies: A Randomized Controlled Clinical Trial

OBJECTIVE

To investigate the efficacy of immersive virtual reality (VR) in combination with standard local anesthetic for mitigating anxiety and pain during US-guided breast biopsies compared to local anesthetic alone.

METHODS

Patients scheduled for US-guided biopsy were invited to participate. Eligible patients were females 18 years of age or older. Patients were randomized to VR or control group at a 1:1 ratio. Patients in the VR group underwent biopsy with the addition of a VR experience and patients in the control group underwent usual biopsy. Patient-perceived levels of anxiety and pain were collected before and after biopsy via the State-Trait Anxiety Inventory (STAI) and Visual Analog Scale (VAS). Physiological data were captured during biopsy using a clinically validated wristband. Differences in anxiety, pain, and physiologic data were compared between the VR and control group.

RESULTS

Sixty patients were enrolled. After excluding 2 patients with VR device malfunction, there were 29 patients in the VR and 29 patients in the control group for analysis. The VR group had reduced anxiety compared to the control group based on postintervention STAI (P <.001) and VAS (P = .036). The VR group did not have lower pain based on postintervention VAS (P = .555). Physiological measures showed higher RR intervals and decreased skin conductance levels, which are associated with lower anxiety levels in the VR group.

CONCLUSION

Use of VR in addition to standard local anesthetic for US-guided breast biopsies was associated with reduced patient anxiety. Virtual reality may be a useful tool to improve the patient biopsy experience.

Diagnostic performance of screening mammography according to menstrual cycle among Asian women

PURPOSE

To investigate the performance metrics of screening mammography according to menstrual cycle week in premenopausal Asian women.

METHODS

This retrospective study included 69,556 premenopausal Asian women who underwent their first screening mammography between 2011 and 2019. The presence or absence of a breast cancer diagnosis within 12 months after the index screening mammography served as the reference standard, determined by linking the study data to the national cancer registry data. Menstrual cycles were calculated, and participants were assigned to groups according to weeks 1-4. The performance metrics included cancer detection rate (CDR), sensitivity, specificity, and positive predictive value (PPV), with comparisons across menstrual cycles.

RESULTS

Among menstrual cycles, the lowest CDR at 4.7 per 1000 women (95% confidence interval [CI], 3.8-5.8 per 1000 women) was observed in week 4 (all P < 0.05). The highest sensitivity of 72.7% (95% CI, 61.4-82.3) was observed in week 1, although the results failed to reach statistical significance. The highest specificity of 80.4% (95% CI, 79.5-81.3%) was observed in week 1 (P = 0.01). The lowest PPV of 2.2% (95% CI, 1.8-2.7) was observed in week 4 (all P < 0.05).

CONCLUSION

Screening mammography tended to show a higher performance during week 1 and a lower performance during week 4 of the menstrual cycle among Asian women. These results emphasize the importance of timing recommendations that consider menstrual cycles to optimize the effectiveness of screening mammography for breast cancer detection.

Artificial intelligence for non-mass breast lesions detection and classification on ultrasound images: a comparative study

BACKGROUND

This retrospective study aims to validate the effectiveness of artificial intelligence (AI) to detect and classify non-mass breast lesions (NMLs) on ultrasound (US) images.

METHODS

A total of 228 patients with NMLs and 596 volunteers without breast lesions on US images were enrolled in the study from January 2020 to December 2022. The pathological results served as the gold standard for NMLs. Two AI models were developed to accurately detect and classify NMLs on US images, including DenseNet121_448 and MobileNet_448. To evaluate and compare the diagnostic performance of AI models, the area under the curve (AUC), accuracy, specificity and sensitivity was employed.

RESULTS

A total of 228 NMLs patients confirmed by postoperative pathology with 870 US images and 596 volunteers with 1003 US images were enrolled. In the detection experiment, the MobileNet_448 achieved the good performance in the testing set, with the AUC, accuracy, sensitivity, and specificity were 0.999 (95%CI: 0.997-1.000),96.5%,96.9% and 96.1%, respectively. It was no statistically significant compared to DenseNet121_448. In the classification experiment, the MobileNet_448 model achieved the highest diagnostic performance in the testing set, with the AUC, accuracy, sensitivity, and specificity were 0.837 (95%CI: 0.990-1.000), 70.5%, 80.3% and 74.6%, respectively.

CONCLUSIONS

This study suggests that the AI models, particularly MobileNet_448, can effectively detect and classify NMLs in US images. This technique has the potential to improve early diagnostic accuracy for NMLs.

Analytic Hierarchy Process Analysis of Patient Preferences for Contrast-Enhanced Mammography Versus MRI as Supplemental Screening Options for Breast Cancer

OBJECTIVE

To guide implementation of supplemental breast screening by assessing patient preferences for contrast-enhanced mammography (CEM) versus MRI using analytic hierarchy process (AHP) methodology.

METHODS

In an institutional review board-approved, HIPAA-compliant protocol, from March 23 to June 3, 2022, we contacted 579 women who had both CEM screening and MRI. Women were e-mailed an invitation to complete an online survey developed using an AHP-based model to elicit preferences for CEM or MRI. Methods for categorical data analysis were used to evaluate factors affecting preferences, under the Bonferroni correction for multiplicity.

RESULTS

Complete responses were received from 222 (38.3%) women; the 189 women with a personal history of breast cancer had a mean age 61.8 years, and the 34 women without a personal history of breast cancer had a mean age of 53.6 years. Of 222 respondents, 157 (70.7%, confidence interval [CI]: 64.7-76.7) were determined to prefer CEM to MRI. Breast positioning was the most important criterion for 74 of 222 (33.3%) respondents, with claustrophobia, intravenous line placement, and overall stress most important for 38, 37, and 39 women (17.1%, 16.7%, and 17.6%), respectively, and noise level, contrast injection, and indifference being emphasized least frequently (by 10 [4.5%], 11 [5.0%], and 13 [5.9%] women, respectively). CEM preference was most prevalent (MRI least prevalent) for respondents emphasizing claustrophobia (37 of 38 [97%], CI: 86.2-99.9); CEM preference was least prevalent (MRI most prevalent) for respondents emphasizing breast positioning (40 of 74 [54%], CI: 42.1-65.7).

CONCLUSIONS

AHP-based modeling reveals strong patient preferences for CEM over MRI, with claustrophobia favoring preference for CEM and breast positioning relatively favoring preference for MRI. Our results should help guide implementation of screening CEM and MRI.

Performance analysis of screening mammography in Asian women under 40 years

BACKGROUND

Screening mammography performance among young women remains uncertain in East Asia, where the proportion of young breast cancer patients is higher than that in Western countries. Thus, we analyzed the performance of screening mammography in women under 40 years in comparison with older age groups.

METHODS

This retrospective study comprised 95,431 Asian women with 197,525 screening mammograms. The reference standard was determined by linkage to the national cancer registry data and the 12-month follow-up outcomes after the index mammogram. The performance metrics included sensitivity, specificity, cancer detection rate (CDR), positive predictive value (PPV), recall rate, and areas under the receiver operating characteristic curve (AUCs), with comparisons across age groups (30 s, 40 s, and ≥ 50 s).

RESULTS

For young women aged < 40 years, sensitivity and AUC (95% confidence interval [CI]) of screening mammography were 60.4% (50.4-69.7) and 0.73 (0.68-0.77), respectively, with no significant difference compared to women in their 40 s (sensitivity: 64.0% [95% CI: 57.8-69.8], P = 0.52; AUC: 0.75 [95% CI: 0.73-0.78], P = 0.35). The CDR (95% CI) was 0.8 (0.6-1.1) per 1,000 mammograms for young women, poorer than 1.8 (1.6-2.1) per 1,000 mammograms for women in their 40 s (P < 0.001). The PPV and recall rate (95% CI) for young women were 0.6% (0.4-0.7) and 14.9% (14.6-15.1), poorer than 1.4% (1.2-1.6) and 13.3% (13.1-13.5) for women in their 40 s (P < 0.001), respectively.

CONCLUSION

The accuracy of screening mammography for young women in their 30 s was not significantly different from that for women in their 40 s, but the cancer detection and recall rates were poorer.

The Landmark Series-Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women

Randomized, clinical trials have established the efficacy of screening mammography in improving survival from breast cancer for women through detection of early, asymptomatic disease. However, disparities in survival rates between black women and women from other racial and ethnic groups following breast cancer diagnosis persist. Various professional groups have different, somewhat conflicting, guidelines with regards to recommended age for commencing screening as well as recommended frequency of screening exams, but the trials upon which these recommendations are based were not specifically designed to examine benefit among black women. Furthermore, these recommendations do not appear to incorporate the unique epidemiological circumstances of breast cancer among black women, including higher rates of diagnosis before age 40 years and greater likelihood of advanced stage at diagnosis, into their formulation. In this review, we examined the epidemiologic and socioeconomic factors that are associated with breast cancer among black women and assess the implications of these factors for screening in this population. Specifically, we recommend that by no later than age 25 years, all black women should undergo baseline assessment for future risk of breast cancer utilizing a model that incorporates race (e.g., Breast Cancer Risk Assessment Tool [BCRAT], formerly the Gail model) and that this assessment should be conducted by a breast specialist or a healthcare provider (e.g., primary care physician or gynecologist) who is trained to assess breast cancer risk and is aware of the increased risks of early (i.e., premenopausal) and biologically aggressive (e.g., late-stage, triple-negative) breast cancer among black women.

Disparities in the Management of Pediatric Breast Masses

INTRODUCTION

Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass.

METHODS

A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses.

RESULTS

A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis.

CONCLUSIONS

We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Addressing Misinformation About the Canadian Breast Screening Guidelines

Screening mammography has been shown to reduce breast cancer mortality by 41% in screened women ages 40-69 years. There is misinformation about breast screening and the Canadian breast screening guidelines. This can decrease confidence in screening mammography and can lead to suboptimal recommendations. We review some of this misinformation to help radiologists and referring physicians navigate the varied international and provincial guidelines. We address the ages to start and stop breast screening. We explore how these recommendations may vary for specific populations such as patients who are at increased risk, transgender patients and minorities. We identify who would benefit from supplemental screening and review the available supplemental screening modalities including ultrasound, MRI, contrast-enhanced mammography and others. We describe emerging technologies including the potential use of artificial intelligence for breast screening. We provide background on why screening policies vary across the country between provinces and territories. This review is intended to help radiologists and referring physicians understand and navigate the varied international and provincial recommendations and guidelines and make the best recommendations for their patients.

Marrying Story with Science: The Impact of Outdated and Inconsistent Breast Cancer Screening Practices in Canada

Behind the science of breast cancer in Canada, as well as globally, are the stories of thousands of women, their families, and their communities. These include stories from those who have died or those suffering from the realities of stage III and stage IV breast cancer due to late detection, misinformation, and dismissal. The reality for these women is that, whilst grateful for the latest developments in cancer research, much of this knowledge is not reflected in policy and practice. Canadian guidelines do not reflect the recommended screening by experts within the field and inequities in screening practices and practitioner knowledge exist in different areas within Canada. Told through the stories of women with lived experiences of late-stage breast cancer and supported by scientific evidence, this paper explores the impact of outdated breast cancer screening practices on the lives of women. Recent patient advocacy is driving changes, such as notifying women of their breast density in a few jurisdictions in Canada, but we call for the whole medical community to take responsibility and ensure breast screening is optimised to save more lives.

Impact of Screening Mammography on Treatment in Young Women Diagnosed with Breast Cancer

BACKGROUND

There is little data exploring the impact of screening mammography on subsequent treatment in the 40-49-year age group with breast cancer. We sought to assess the association between frequency of mammography in young women and extent of surgery and chemotherapy required.

METHODS

An IRB-approved retrospective review was performed of patients diagnosed with breast cancer between ages 40 and 49 years from 1 January 2010 to 19 November 2018 within a single health system. Patients were grouped based on last screening 1-24 months prior to diagnosis (1-24 group), > 25 months prior to diagnosis (> 25 group), never screened, and > 25+ never screened (combination group). Multivariate logistic regression models were used to assess for associations between screening intervals and tumor and nodal stage, chemotherapy use, and extent of surgery.

RESULTS

Of 869 patients included for analysis, 20% were never screened, 60% screened 1-24 months, and 19% screened > 25 months prior to diagnosis. Compared with the 1-24 months group, the never-screened group, > 25 months group, and combined group were more likely to receive chemotherapy. The never-screened and combined groups were more likely to undergo mastectomy and/or axillary lymph node dissection. Of patients undergoing upfront surgery, the > 25 months and combined groups were more likely to receive adjuvant chemotherapy, while the never-screened and combined groups were more likely to have nodal disease.

CONCLUSION

Our findings support the initiation of screening mammography at age 40 years to reduce the risk of aggressive treatments for newly diagnosed breast cancers in this group.

Barriers to breast cancer screening are worsened amidst COVID-19 pandemic: A review

Disparities in screening mammography and barriers to accessing breast cancer screening are most prevalent among racial/ethnic minority and low-income women. The significant breast cancer mortality rates experienced in both Hispanic and African American populations are found to be connected to delayed screening. For these women to follow the screening guidelines outlined by the American College of Radiology and Society of Breast Imaging, they must successfully navigate existing barriers to screening. These barriers include differential access to care, language barriers, and lack of medical insurance. The COVID-19 Pandemic has worsened the barriers to breast cancer screening faced by these groups of women. These barriers need to be addressed or they may further exacerbate disparities.

True and Missed Interval Cancer in Organized Mammographic Screening: A Retrospective Review Study of Diagnostic and Prior Screening Mammograms

RATIONALE AND OBJECTIVES

To explore radiological aspects of interval breast cancer in a population-based screening program.

MATERIALS AND METHODS

We performed a consensus-based informed review of mammograms from diagnosis and prior screening from women diagnosed with interval cancer 2004-2016 in BreastScreen Norway. Cases were classified as true (no findings on prior screening mammograms), occult (no findings at screening or diagnosis), minimal signs (minor/non-specific findings) and missed (obvious findings). We analyzed mammographic findings, density, time since prior screening, and histopathological characteristics between the classification groups.

RESULTS

The study included 1010 interval cancer cases. Mean age at diagnosis was 61 years (SD = 6), mean time between screening and diagnosis 14 months (SD = 7). A total of 48% (479/1010) were classified as true or occult, 28% (285/1010) as minimal signs and 24% (246/1010) as missed. We observed no differences in mammographic density between the groups, except from a higher percentage of dense breasts in women with occult cancer. Among cancers classified as missed, about 1/3 were masses and 1/3 asymmetries at prior screening. True interval cancers were diagnosed later in the screening interval than the other classification categories. No differences in histopathological characteristics were observed between true, minimal signs and missed cases.

CONCLUSION

In an informed review, 24% of the interval cancers were classified as missed based on visibility and mammographic findings on prior screening mammograms. Three out of four true interval cancers were diagnosed in the second year of the screening interval. We observed no statistical differences in histopathological characteristics between true and missed interval cancers.

An Early Breast Cancer Detection System Using Recurrent Neural Network (RNN) with Animal Migration Optimization (AMO) Based Classification Method

Breast cancer can be detected using early signs of it mammograms and digital mammography. For Computer Aided Detection (CAD), algorithms can be developed using this opportunities. Early detection is assisted by self-test and periodical check-ups and it can enhance the survival chance significantly. Due the need of breast cancer’s early detection and false diagnosis impact on patients, made researchers to investigate Deep Learning (DL) techniques for mammograms. So, it requires a non-invasive cancer detection system, which is highly effective, accurate, fast as well as robust. Proposed work has three steps, (i) Pre-processing, (ii) Segmentation, and (iii) Classification. Firstly, preprocessing stage removing noise from images by using mean and median filtering algorithms are used, while keeping its features intact for better understanding and recognition, then edge detection by using canny edge detector. It uses Gaussian filter for smoothening image. Gaussian smoothening is used for enhancing image analysis process quality, result in blurring of fine-scaled image edges. In the next stage, image representation is changed into something, which makes analyses process as a simple one. Foreground and background subtraction is used for accurate breast image detection in segmentation. After completion of segmentation stage, the remove unwanted image in input image dataset. Finally, a novel RNN forclassifying and detecting breast cancer using Auto Encoder (AE) based RNN for feature extraction by integrating Animal Migration Optimization (AMO) for tuning the parameters of RNN model, then softmax classifier use RNN algorithm. Experimental results are conducted using Mini-Mammographic (MIAS) dataset of breast cancer. The classifiers are measured through measures like precision, recall, f-measure and accuracy.

Breast cancer screening in average and high-risk women

Breast cancer is the most common cancer among females worldwide with rising incidence. In the United States, screening mammography and advances in therapy have lowered mortality by 41% since 1990. Screening mammography is supported by randomized control trials (RCT), observational studies, and computer model data. Digital breast tomosynthesis is a new technology that addresses limitations in mammography resulting from overlapping breast tissue, improving its sensitivity and specificity. Patients at high risk for breast cancer include those with a ≥20% lifetime risk, high-risk germline mutation, or history of thoracic radiation treatment between 10-30 years of age. Such patients are recommended to undergo annual screening mammography and adjunctive annual screening breast MRI. Patients unable to undergo MRI may undergo whole breast ultrasound or contrast-enhanced mammography. Pregnant and lactating patients at average risk for breast cancer are recommended to undergo age-appropriate screening mammography.

Existing and Emerging Breast Cancer Detection Technologies and Its Challenges: A Review

Breast cancer is the most leading cancer occurring in women and is a significant factor in female mortality. Early diagnosis of breast cancer with Artificial Intelligent (AI) developments for breast cancer detection can lead to a proper treatment to affected patients as early as possible that eventually help reduce the women mortality rate. Reliability issues limit the current clinical detection techniques, such as Ultra-Sound, Mammography, and Magnetic Resonance Imaging (MRI) from screening images for precise elucidation. The capability to detect a tumor in early diagnosis, expensive, relatively long waiting time due to pandemic and painful procedure for a patient to perform. This article aims to review breast cancer screening methods and recent technological advancements systematically. In addition, this paper intends to explore the progression and challenges of AI in breast cancer detection. The next state of the art between image and signal processing will be presented, and their performance is compared. This review will facilitate the researcher to insight the view of breast cancer detection technologies advancement and its challenges.

Effect of Out-of-Pocket Costs on Subsequent Mammography Screening

OBJECTIVE

Although the Affordable Care Act eliminated cost sharing for screening mammography, a concern is that grandfathered plans, diagnostic mammograms, and follow-up testing may still lead to out-of-pocket (OOP) spending. Our study examines how OOP spending among women at their baseline screening mammogram may impact the decision to receive subsequent screening.

METHODS

The study included commercially insured women aged 40 to 41 years with a screening mammogram between 2011 and 2014. We estimated multivariate linear probability models of the effect of OOP spending at the baseline mammogram on subsequent screening 12 to 36 months later.

RESULTS

Having any OOP payments for the baseline screening mammogram significantly reduced the probability of screening in the subsequent 12 to 24 months by 3.0 percentage points (pp) (95% confidence interval [CI]: 1.1-4.8 pp decrease). For every $100 increase in the OOP expenses for the baseline mammogram, the likelihood of subsequent screening within 12 to 24 months decreased by 1.9 pp (95% CI: 0.8-3.1 pp decrease). Similarly, any OOP spending for follow-up tests resulting from the baseline screening led to a 2.7 pp lower probability of screening 12 to 24 months later (95% CI: 0.9-4.1 pp decrease). Higher OOP expenses were associated with significantly lower screening 24 to 36 months later (coefficient = -0.014, 95% CI: -0.025 to -0.003).

DISCUSSION

Although cost sharing has been eliminated for screening mammograms, OOP costs may still arise, particularly for diagnostic and follow-up testing services, both of which may reduce rates of subsequent screening. For preventive services, reducing or eliminating cost sharing through policy and legislation may be important to ensuring continued adherence to screening guidelines.

Artificial intelligence system reduces false-positive findings in the interpretation of breast ultrasound exams

Though consistently shown to detect mammographically occult cancers, breast ultrasound has been noted to have high false-positive rates. In this work, we present an AI system that achieves radiologist-level accuracy in identifying breast cancer in ultrasound images. Developed on 288,767 exams, consisting of 5,442,907 B-mode and Color Doppler images, the AI achieves an area under the receiver operating characteristic curve (AUROC) of 0.976 on a test set consisting of 44,755 exams. In a retrospective reader study, the AI achieves a higher AUROC than the average of ten board-certified breast radiologists (AUROC: 0.962 AI, 0.924 ± 0.02 radiologists). With the help of the AI, radiologists decrease their false positive rates by 37.3% and reduce requested biopsies by 27.8%, while maintaining the same level of sensitivity. This highlights the potential of AI in improving the accuracy, consistency, and efficiency of breast ultrasound diagnosis.

Screening mammography mitigates breast cancer disparities through early detection of triple negative breast cancer

PURPOSE

Screening mammography improves breast cancer survival through early detection, but Triple Negative Breast Cancer (TNBC) is more difficult to detect on mammography and has lower survival compared to non-TNBC, even when detected at early stages. TNBC is twice as common among African American (AA) compared to White American (WA) women, thereby contributing to the 40% higher breast cancer mortality rates observed in AA women. The role of screening mammography in addressing breast cancer disparities is therefore worthy of study.

METHODS

Outcomes were evaluated for TNBC patients treated in the prospectively-maintained databases of academic cancer programs in two metropolitan cities of the Northeast and Midwest, 1998-2018.

RESULTS

Of 756 TNBC cases, 301 (39.8%) were mammographically screen-detected. 46% of 189 AA and 38.5% of 460 WA patients had screen-detected TNBC (p = 0.16). 25.3% of 257 TNBC cases ≤50 years old had screen-detected disease compared to 47.3% of 499 TNBC cases >50 years old (p < 0.0001). 220/301 (73.1%) screen-detected TNBC cases were T1 lesions versus 118/359 (32.9%) non-screen-detected cases (p < 0.0001). Screen-detected TNBC was more likely to be node-negative (51.9% v. 40.4%; p < 0.0001). Five-year overall survival was better in screen-detected TNBC compared to nonscreen-detected TNBC (92.8% v. 81.5%; p < 0.0001) in the entire cohort. The magnitude of this effect was most significant among AA patients (Fig. 1). Screening-related survival patterns were similar among AA and WA patients in both cities.

CONCLUSION

Data from two different cities demonstrates the value of screening mammography to mitigate breast cancer disparities in AA women through the early detection of TNBC.

Surgical Management of Hereditary Breast Cancer

The identification that breast cancer is hereditary was first described in the nineteenth century. With the identification of the BRCA1 and BRCA 2 breast/ovarian cancer susceptibility genes in the mid-1990s and the introduction of genetic testing, significant advancements have been made in tailoring surveillance, guiding decisions on medical or surgical risk reduction and cancer treatments for genetic variant carriers. This review discusses various medical and surgical management options for hereditary breast cancers.

Evaluation of Adjunctive Ultrasonography for Breast Cancer Detection Among Women Aged 40-49 Years With Varying Breast Density Undergoing Screening Mammography: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Mammography has limited accuracy in breast cancer screening. Ultrasonography, when used in conjunction with mammography screening, is helpful to detect early-stage and invasive cancers for asymptomatic women with dense and nondense breasts.

OBJECTIVE

To evaluate the performance of adjunctive ultrasonography with mammography for breast cancer screening, according to differences in breast density.

DESIGN, SETTING, AND PARTICIPANTS

This study is a secondary analysis of the Japan Strategic Anti-cancer Randomized Trial. Between July 2007 and March 2011, asymptomatic women aged 40 to 49 years were enrolled in Japan. The present study used data from cases enrolled from the screening center in Miyagi prefecture during 2007 to 2020. Participants were randomly assigned in a 1:1 ratio to undergo either mammography with ultrasonography (intervention group) or mammography alone (control group). Data analysis was performed from February to March 2020.

EXPOSURES

Ultrasonography adjunctive to mammography for breast cancer screening regardless of breast density.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, recall rates, biopsy rates, and characteristics of screen-detected cancers and interval breast cancers were evaluated between study groups and for each modality according to breast density.

RESULTS

A total of 76 119 women were enrolled, and data for 19 213 women (mean [SD] age, 44.5 [2.8] years) from the Miyagi prefecture were analyzed; 9705 were randomized to the intervention group and 9508 were randomized to the control group. A total of 11 390 women (59.3%) had heterogeneously or extremely dense breasts. Among the overall group, 130 cancers were found. Sensitivity was significantly higher in the intervention group than the control group (93.2% [95% CI, 87.4%-99.0%] vs 66.7% [95% CI, 54.4%-78.9%]; P < .001). Similar trends were observed in women with dense breasts (sensitivity in intervention vs control groups, 93.2% [95% CI, 85.7%-100.0%] vs 70.6% [95% CI, 55.3%-85.9%]; P < .001) and nondense breasts (sensitivity in intervention vs control groups, 93.1% [95% CI, 83.9%-102.3%] vs 60.9% [95% CI, 40.9%-80.8%]; P < .001). The rate of interval cancers per 1000 screenings was lower in the intervention group compared with the control group (0.5 cancers [95% CI, 0.1-1.0 cancers] vs 2.0 cancers [95% CI, 1.1-2.9 cancers]; P = .004). Within the intervention group, the rate of invasive cancers detected by ultrasonography alone was significantly higher than that for mammography alone in both dense (82.4% [95% CI, 56.6%-96.2%] vs 41.7% [95% CI, 15.2%-72.3%]; P = .02) and nondense (85.7% [95% CI, 42.1%-99.6%] vs 25.0% [95% CI, 5.5%-57.2%]; P = .02) breasts. However, sensitivity of mammography or ultrasonography alone did not exceed 80% across all breast densities in the 2 groups. Compared with the control group, specificity was significantly lower in the intervention group (91.8% [95% CI, 91.2%-92.3%] vs 86.8% [95% CI, 86.2%-87.5%]; P < .001). Recall rates (13.8% [95% CI, 13.1%-14.5%] vs 8.6% [95% CI, 8.0%-9.1%]; P < .001) and biopsy rates (5.5% [95% CI, 5.1%-6.0%] vs 2.1% [95% CI, 1.8%-2.4%]; P < .001) were significantly higher in the intervention group than the control group.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, screening mammography alone demonstrated low sensitivity, whereas adjunctive ultrasonography was associated with increased sensitivity. These findings suggest that adjunctive ultrasonography has the potential to improve detection of early-stage and invasive cancers across both dense and nondense breasts. Supplemental ultrasonography should be considered as an appropriate imaging modality for breast cancer screening in asymptomatic women aged 40 to 49 years regardless of breast density.

TRIAL REGISTRATION

NIPH Clinical Trial Identifier: UMIN000000757.

Breast Cancer in Jamaica: Stage, Grade and Molecular Subtype Distributions Across Age Blocks, the Implications for Screening and Treatment

BACKGROUND

Breast cancer is the most commonly diagnosed and leading cause of cancer-related morbidity and mortality in females worldwide. Significant disparities exist in breast cancer incidence and mortalities between low- to middle- and high-income countries. The purpose of this study was to analyze the distribution of prognostic and predictive clinicopathological features of invasive breast cancer at a single institution in Jamaica across three age groups.

METHODS

Data from patients diagnosed with invasive breast cancer who underwent definitive surgery between August 2017 and September 2018 were identified. The patients were divided into three age groups (< 50, 50 - 59 and > 59 years) and the distribution of tumor size, grade, molecular subtype, nodal status and anatomic stage were determined and compared with the US population registry. Comparisons of the various characteristics were performed using the Fisher's exact test.

RESULTS

Ninety-nine definitive operations were performed and met the criteria for analysis. Average age at the time of diagnosis was 54 years compared to 62 years reported in the US databases. Thirty-six percent of the patients presented below age 50 years, which was twice the corresponding rate reported for Caucasian females (18%) in the USA. Fifty percent of patients in our registry had axillary lymph node metastases at presentation and they were younger than patients with negative axillary nodes (95% confidence interval (CI) -12.06 to -1.93, P = 0.007). Patients in the age group less than age 50 years were more likely to have advanced stage, high histological grade cancers compared to the older age blocks (95% CI 0.039 - 0.902, P = 0.033).

CONCLUSION

Invasive breast cancer presents at an earlier age in Jamaican women and is associated with poor prognostic features such as high rates of axillary lymph node metastases, high histological grade, advanced stage, triple-negative subtypes and low luminal A subtypes.

Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.

Developing a Culturally and Linguistically Targeted Breast Cancer Educational Program for a Multicultural Population

Breast cancer is the most commonly diagnosed cancer among women in the USA. Despite the availability of screening mammograms, significant disparities still exist in breast cancer outcomes of racial/ethnic and sexual/gender minorities. To address these disparities, the Mount Sinai Mobile Breast Health Program in New York City collaborated with local organizations to develop culturally and linguistically appropriate breast cancer education programs aimed at increasing screening mammogram utilization. Literature review of the barriers to mammography screening formed the basis to allow us to draft a narrative presentation for each targeted cultural group: African American, African-born, Chinese, Latina, and Muslim women, as well as LGBTQ individuals. The presentations were then tested with focus groups comprised of gatekeepers and members from local community and faith-based organizations which served the targeted populations. Feedback from focus groups and gatekeepers was incorporated into the presentations, and if necessary, the presentations were translated. Subsequently, the presentations were re-tested for appropriateness and reviewed for consistency in message, design, educational information, and slide sequencing. Our experience demonstrated the importance of collaborating with community organizations to provide educational content that is culturally and linguistically appropriate for minority groups facing barriers to uptake of screening mammography.

Project ScanVan: Mobile mammography services to decrease socioeconomic barriers and racial disparities among medically underserved women in NYC

OBJECTIVE

To evaluate whether, with access to free screening services, uninsured minority women in NYC are able to successfully manage existing barriers to breast cancer screening.

METHODS

This is a retrospective cohort study, with permission to use de-identified data received from Project Renewal's ScanVan in 2019. Project Renewal ScanVan provides clinical breast exams, mammograms, and health education to low-income women. The screening mammograms were conducted in the ScanVan and read by a board-certified radiologist. The electronic medical records were reviewed with respect to the patients' BI-RADS category, insurance status, race, and age. Descriptive statistics were performed and cancer detection rate, recall rate, and positive predictive values (PPV1, PPV2, PPV3) were calculated.

RESULTS

In 2019, 66% (2499 of 3745) of patients who used the ScanVan were Hispanic & African American. 43% (1627 of 3745) of the women were uninsured, 15% (579 of 3745) of the women had Medicare, and 18% (676 of 3745) classified as other. 17 out of 3745 patients screened received a new diagnosis of breast cancer, corresponding to a cancer detection rate of 4.5/1000 screened. 258 were recalled, corresponding with a recall rate of 7%. The PPV1 was 6.5% (17/258); PPV2 was 29.8% (17/57); and PPV3 was 34% (17/50).

CONCLUSION

Barriers to breast cancer screening include lack of medical insurance, limited access to care, and the absence of a primary care physician. The mobile mammography screening van successfully overcame such barriers, providing uninsured women from racial minority groups with vital breast cancer screening and follow up care.

Breast Cancer Screening in Inner City and County Populations: A Tale of Two Centers

BACKGROUND

New York's statewide "Get Screened, No Excuses" campaign has been one of the nation's most aggressive actions to improve access to breast cancer screening. Inner city and suburban county medical centers' initiatives were studied to compare outcomes of breast cancer screening and factors that influence access to care.

METHODS

Women delinquent in breast cancer screening one year or greater were offered patient navigator services to aid in timely breast cancer screening. Time-to-event completion rates among different stages of breast cancer screening stages in City and County women were compared. Time-to-event completion rates among different stages of breast cancer screening stages.

RESULTS

2505 women aged ≥40 years accepted PN services. Mean (SD) age of patients was 56.2 (10) years. The mean (SD) age of those who completed breast screening vs. those who did not was 56.8 (10) and 52.5 (.9) years, respectively (P < .01). The rates of screening completion during physical examination, mammography and biopsy stages were 74%, 78% and 100% in City vs. 98%, 85% and 100% in County, respectively (P < .001). Screening phase was the significant predictor of time to completion for breast cancer screening in Cox regression analysis. Over 85% of women completed the breast cancer screening, 74% in City and 97.6% in County (P < .001).

DISCUSSION

Screening phase is an important predictor of time-to complete breast cancer screening. Center location served as the effect modifier of the relationship. The rate of completing the screening was significantly higher and faster among Suburban County compared to Inner City women.

Overdiagnosis and Risks of Breast Cancer Screening

Since its widespread introduction 30 years ago, screening mammography has contributed to substantial reduction in breast cancer-associated mortality, ranging from 15% to 50% in observational trials. It is currently the best examination available for the early diagnosis of breast cancer, when survival and treatment options are most favorable. However, like all medical tests and procedures, screening mammography has associated risks, including overdiagnosis and overtreatment, false-positive examinations, false-positive biopsies, and radiation exposure. Women should be aware of the benefits and risks of screening mammography in order to make the most appropriate care decisions for themselves.

Characterization of breast masses: a comparative study between automated breast ultrasound (ABUS) and digital breast tomosynthesis (DBT)

Background

Automated three-dimensional (3D) breast ultrasound (US) systems and breast tomosynthesis are promising breast imaging modalities. The study aims to compare the diagnostic indices of the 3D imaging techniques: digital breast tomosynthesis (DBT) and automated breast ultrasound (ABUS) in the characterization of breast masses. This prospective study included 32 women with breast masses either detected by means of clinical examination or with the mammographic exam. All of them have been subjected to tomosynthesis and automatic breast ultrasound examinations. The images from both modalities were then analyzed one at a time by two experienced representative radiologists in consensus. Results were compared to each other and to pathology and follow-up of typically benign findings

Results

The masses statistically evaluated in this study were 37 in number, among which 16 were benign and 21 were malignant. The sensitivity and specificity of tomosynthesis in the characterization of breast masses were 100% and 81.25%, respectively, while automated breast ultrasound were 100% and 75%, respectively.

Conclusion

Tomosynthesis and automated breast ultrasound are two promising modalities in breast imaging. Their diagnostic indices in this study were very close to one another; therefore, they can be used as an adjunct modality to mammography for early diagnosis of breast cancer.

The wisdom trial is based on faulty reasoning and has major design and execution problems

PURPOSE

To evaluate the design and plan of execution of the "WISDOM" trial.

METHODS

The rationale and reasoning behind the WISDOM Trial were reviewed and analyzed. The published parameters of the trial were reviewed.

RESULTS

The study is based on a failed understanding of the available data about breast cancer screening and is based on faulty assumptions, false reasoning, a scientifically unsupportable study design, ignoring advances in screening, a questionable endpoint, the likely lacking of power to answer the primary question, and support by insurance companies whose primary goal is almost certainly to reduce their costs.

CONCLUSION

A major part of the premise is that there is a "debate" about the efficacy of screening. WISDOM ignores the fact that the "debate" has been manufactured and is not science-based. The results of the WISDOM Trial may be misleading.

Lifting the fog of confusion about breast cancer screening guidelines: Surprise - it's about the money!

Large amounts of misinformation denigrating the benefits of breast cancer screening have been published over the past 50 years and continue to be published. Each effort to reduce breast cancer screening has been refuted, scientifically, but the efforts continue. The motivation has been unclear until the recent guidelines issued by the American Society of Breast Surgeons who support annual screening starting at the age of 40 contrasted with the American College of Physicians who advocated delaying screening until the age of 50 and then biennially. An analysis of the facts can only lead to the conclusion that delayed screening has been chosen to save money rather than lives.

Current Guidelines and Gaps in Breast Cancer Screening

Breast cancer is the most common nonskin cancer in women and the second leading cause of cancer death for women in the United States. Mammography screening is proven to significantly decrease breast cancer mortality, with a 40% or more reduction expected with annual use starting at age 40 for women of average risk. However, less than half of all eligible women have a mammogram annually. The elimination of cost sharing for screening made possible by the Affordable Care Act (2010) encouraged screening but mainly for those already insured. The United States Preventive Services Task Force 2009 guidelines recommended against screening those 40 to 49 years old and have left women over 74 years of age vulnerable to coverage loss. Other populations for whom significant gaps in risk information or screening use exist, including women of lower socioeconomic status, black women, men at higher than average risk of breast cancer, and sexual and gender minorities. Further work is needed to achieve higher rates of screening acceptance for all appropriate individuals so that the full mortality and treatment benefits of mammography screening can be realized.

Mapping mammography in Arkansas: Locating areas with poor spatial access to breast cancer screening using optimization models and geographic information systems

Introduction:

Arkansans have some of the worst breast cancer mortality to incidence ratios in the United States (5th for Blacks, 4th for Whites, 7th overall). Screening mammography allows for early detection and significant reductions in mortality, yet not all women have access to these life-saving services. Utilization in Arkansas is well below the national average, and the number of FDA-approved screening facilities has decreased by 38% since 2001. Spatial accessibility plays an important role in whether women receive screenings.

Methods:

We use constrained optimization models within a geographic information system (GIS) to probabilistically allocate women to nearby screening facilities, accounting for facility capacity and patient travel time. We examine accessibility results by rurality derived from rural–urban commuting area (RUCA) codes.

Results:

Under most models, screening capacity is insufficient to meet theoretical demand given travel constraints. Approximately 80% of Arkansan women live within 30 minutes of a screening facility, most of which are located in urban and suburban areas. The majority of unallocated demand was in Small towns and Rural areas.

Conclusions:

Geographic disparities in screening mammography accessibility exist across Arkansas, but women living in Rural areas have particularly poor spatial access. Mobile mammography clinics can remove patient travel time constraints to help meet rural demand. More broadly, optimization models and GIS can be applied to many studies of healthcare accessibility in rural populations.

Age-related disparities in older women with breast cancer

Improvements in breast cancer (BC) mortality rates have not been seen in the older adult community, and the fact that older adults are more likely to die from their cancer than younger women establishes a major health disparity. Studies have identified that despite typically presenting with more favorable histology, older women present with more advanced disease, which may be related in part to delayed diagnosis. This is supported by examination of screening practices in older adults. Older women have a worse prognosis than younger women in both early stage disease, and more advanced and metastatic disease. Focus on the treatment of older adults has often concentrated on avoiding overtreatment, but in fact undertreatment may be one reason for the age-related differences in outcomes, and treatments need to be individualized for every older adult, and take into account patient preferences and functional status and not chronologic age alone. Given the aging population in the US, identifying methods to improve early diagnosis in this population and identify additional factors will be important to reducing this age-related disparity.

Screening mammography with special reference to guidelines in South Africa

Screening mammography is known to reduce mortality from breast cancer. Controversy regarding screening has led to much confusion in the medical fraternity. The purpose of this review is to point out the 'pros and cons' of screening. The benefits and perceived harms of screening will be discussed using evidence-based literature from the past 30 years. The literature was obtained from various journals sourced from the Internet. General findings are that screening mammography from the age of 40 saves lives, but that the problem of overdiagnosis and overtreatment of certain breast cancers overrides the benefit of screening. The article also covers the debate on what age to begin screening. Screening in the South African context is discussed. Screening in the future will need to be more selective of patients and of which cancers to treat less aggressively, if at all.

Factors Impacting False Positive Recall in Screening Mammography

RATIONALE AND OBJECTIVES

Our objective was to identify factors impacting false positive recalls in screening mammography.

MATERIALS AND METHODS

We retrospectively reviewed our screening mammography database from August 31, 2015 to September 30, 2016, including full field digital mammograms (FFDM) and digital breast tomosynthesis (DBT) mammograms. False positive (FP) exams were defined as Breast Imaging-Reporting and Data System (BI-RADS) 1 or 2 assessments at diagnostic imaging with 1 year cancer-free follow-up, Breast Imaging-Reporting and Data System 3 assessment at diagnostic imaging with 2 years cancer free follow-up, or biopsy with benign pathology. True positives were defined as malignant pathology on biopsy or surgical excision. We evaluated the association of FP recalls with multiple patient-level factors and imaging features.

RESULTS

A total of 22,055 screening mammograms were performed, and 1887 patients were recalled (recall rate 8.6%). Recall rate was lower for DBT than full field digital mammograms (8.0% vs 10.6%, p < 0.001). FP results were lower if prior mammograms were available (90.8% vs 95.8%, p = 0.02), and if there was a previous benign breast biopsy (87.6% vs 92.9%, p = 0.01). Mean age for the FP group was lower than the true positive group (56.1 vs 62.9 years, p < 0.001). There were no significant differences in FP recalls based on history of high-risk lesions, family history of breast or ovarian cancer, hormone use, breast density, race, or body mass index.

CONCLUSION

FP recalls were significantly less likely with DBT, in older women, in patients with prior mammograms available for comparison, and in patients with histories of benign breast biopsy. This study supports the importance of using DBT in the screening setting and obtaining prior mammograms for comparison.

Evidence of Benefit from Mammography Screening of Average-Risk Women Ages 40-49 Years: Science, Metrics, and Value Judgments

The majority of randomized control trials and service-based screening studies of women ages 40-49 years demonstrate reductions in mortality of 29%-48% when long-term outcome is assessed. Annual screening is preferable in these younger women due to faster tumor-doubling times. Advances in mammography technique and breast ultrasound may allow even better results in the future.

Discordance in Clinical Recommendations Regarding the Use of Imaging

As physicians strive to provide evidence-based care, challenges arise if different entities disseminate divergent Appropriate Use Criteria (AUC) or clinical guidelines on the same topic. To characterize these challenges in one field, this study reviews the literature on comparisons of clinical recommendations regarding medical imaging. The PubMed database was searched for the years 2013-2018 for studies describing discordance among clinical recommendations regarding the performance of imaging. Of the 406 articles identified, 15 met the selection criteria: 8 qualitative and 7 quantitative. Reasons for discordance varied, with lack of evidence often cited. Quantitative studies often found that different decisions would be reached depending on the clinical recommendation followed. Nonetheless, quantitative studies also tended not to consider one set of recommendations superior to another. The findings of this review might help clinicians seek guidance more thoughtfully and could inform use of guidelines and AUC for quality improvement and clinical decision support.

Genetic Testing to Guide Risk-Stratified Screens for Breast Cancer

Breast cancer screening modalities and guidelines continue to evolve and are increasingly based on risk factors, including genetic risk and a personal or family history of cancer. Here, we review genetic testing of high-penetrance hereditary breast and ovarian cancer genes, including BRCA1 and BRCA2, for the purpose of identifying high-risk individuals who would benefit from earlier screening and more sensitive methods such as magnetic resonance imaging. We also consider risk-based screening in the general population, including whether every woman should be genetically tested for high-risk genes and the potential use of polygenic risk scores. In addition to enabling early detection, the results of genetic screens of breast cancer susceptibility genes can be utilized to guide decision-making about when to elect prophylactic surgeries that reduce cancer risk and the choice of therapeutic options. Variants of uncertain significance, especially missense variants, are being identified during panel testing for hereditary breast and ovarian cancer. A finding of a variant of uncertain significance does not provide a basis for increased cancer surveillance or prophylactic procedures. Given that variant classification is often challenging, we also consider the role of multifactorial statistical analyses by large consortia and functional tests for this purpose.