Analysis of prior mammography with negative result in women with interval breast cancer

Risk Factors and Mortality Among Women With Interval Breast Cancer vs Screen-Detected Breast Cancer

Importance

The risk factors for interval breast cancer (IBC) compared with those for screen-detected breast cancer (SBC) and their association with mortality outcomes have not yet been evaluated among Korean women.

Objective

To evaluate risk factors associated with IBC and survival among Korean women with IBC compared with those with SBC.

Design, Setting, and Participants

This retrospective cohort study used data from the Korean National Health Insurance Service Database. Women who participated in a national mammographic breast cancer screening program between January 1, 2009, and December 31, 2012, were included. Mortality outcomes were calculated from the date of breast cancer diagnosis to the date of death or December 31, 2020. Data were analyzed from March 1 to June 30, 2023.

Exposure

Breast cancer diagnosed within 6 to 24 months after a negative screening result (ie, IBC) or within 6 months after a positive screening result (ie, SBC).

Main Outcomes and Measures

Risk factors and survival rates for IBC and SBC.

Results

This study included 8702 women with IBC (mean [SD] age, 53.3 [8.6] years) and 9492 women with SBC (mean [SD] age, 54.1 [9.0] years). Compared with SBC, the probability of IBC decreased as mammographic density increased. Lower body mass index, menopausal status, hormone replacement therapy (HRT) use, and lack of family history of breast cancer were associated with a higher likelihood of IBC. When stratified by detection time, younger age at breast cancer diagnosis and family history of breast cancer were associated with an increased likelihood of IBC diagnosed at 6 to 12 months but a decreased likelihood of IBC diagnosed at 12 to 24 months. Overall mortality of IBC was comparable with SBC, but total mortality and cancer-related mortality of IBC diagnosed between 6 and 12 months was higher than that of SBC.

Conclusions and Relevance

The findings of this cohort study suggest that breast density, obesity, and HRT use were associated with IBC compared with SBC. These findings also suggest that higher supplemental breast ultrasound use among Korean women, especially those with dense breasts, could be attributed to a lower incidence of IBC among women with dense breasts compared with women with SBC, due to greater detection. Finally, overall mortality of IBC was comparable with that of SBC.

Imaging characteristics of interval cancers detected on Full Field Digital Mammography (FFDM) versus Digital Breast Tomosynthesis (DBT)

OBJECTIVE

To compare imaging features of interval cancers detected in patients screened with full field digital mammography (FFDM) versus digital breast tomosynthesis (DBT).

MATERIALS/METHODS

This retrospective observational study consisted of female patients undergoing screening DM or FFDM at an academic medical center and two outpatient imaging facilities between January 2012 and June 2017. A natural language processing algorithm queried breast imaging reports for breast density and BI-RADS category. This was cross-referenced to an institutional breast cancer registry to identify interval cancers. Retrospective consensus review of the cases was done to categorize imaging features of interval cancers on FFDM vs DBT.

RESULTS

The rate of interval cancers was comparable in patients screened with FFDM (30/39793) and DBT (29/32180) (p = 0.58). There was no significant difference in the rate, histopathology, or imaging features of interval cancers in patients screened with FFDM versus DBT. The most common mammographic features on diagnostic imaging across both groups was the presence of a mass (13/47). Almost equally common was negative diagnostic mammogram with mass detected only on ultrasound (11/47). The rate of interval cancers detected by high-risk surveillance breast MRI was increased in patients who previously had screening with DBT relative to those who had screening with FFDM (p = 0.0419).

CONCLUSION

There is no significant difference in rate of detection, histopathology, or imaging features of interval cancers in patients screened with FFDM versus DBT. However, across both cohorts, the most common features on diagnostic mammogram were either the presence of a mass or a negative mammogram.

Diagnostic performance of two versions of an artificial intelligence system in interval breast cancer detection

BACKGROUND

Various versions of artificial intelligence (AI) have been used as a diagnostic tool aid in the diagnosis of breast cancer. One of the most important problems in breast screening progmrams is interval breast cancer (IBC).

PURPOSE

To compare the diagnostic performance of Transpara v1.6 and v1.7 in the detection of IBC.

MATERIAL AND METHODS

Reports of screening mammograms of a total 2,248,665 of women were evaluated retrospectively. Of 2,129,486 mammograms reported as Breast Imaging Reporting and Data System (BIRADS) 1 and 2, the IBC group consisted of 323 cases who were diagnosed as having cancer on mammography and were correlated with pathology in second mammogram taken >30 days after first mammogram. Four hundred and forty-one were defined as the control group because they did not change over 2 years. Cancer risk scores of both groups were determined from 1 to 10 with Tranpara v1.6 and v1.7. Diagnostic performances of both versions were evaluated by the receiver operating characteristic curve.

RESULTS

Cancer risk scores 1 and 10 in v1.7 increased compared to v1.6 (P < 0.001). In all cases, sensitivity for v1.6 was 56.6%, specificity was 90%, and, for v1.7, sensitivity was 65.9% and specificity was 90%, respectively. In all cases, area under the curve values were 0.812 for v1.6 and 0.856 for v1.7, which was higher in v1.7 (P < 0.001). Diagnostic performance of v1.7 was higher than v1.6 at the 7-12-month period (P < 0.001).

CONCLUSION

The present study showed that Tranpara v1.7 has a higher specificity, sensitivity and diagnostic performance in IBC determination than v1.6. AI systems can be used in breast screening as a secondary or third reader in screening programs.

Isogenic Mammary Models of Intraductal Carcinoma Reveal Progression to Invasiveness in the Absence of a Non-Obligatory In Situ Stage

In breast cancer, progression to invasive ductal carcinoma (IDC) involves interactions between immune, myoepithelial, and tumor cells. Development of IDC can proceed through ductal carcinoma in situ (DCIS), a non-obligate, non-invasive stage, or IDC can develop without evidence of DCIS and these cases associate with poorer prognosis. Tractable, immune-competent mouse models are needed to help delineate distinct mechanisms of local tumor cell invasion and prognostic implications. To address these gaps, we delivered murine mammary carcinoma cell lines directly into the main mammary lactiferous duct of immune-competent mice. Using two strains of immune-competent mice (BALB/c, C57BL/6), one immune-compromised (severe combined immunodeficiency; SCID) C57BL/6 strain, and six different murine mammary cancer cell lines (D2.OR, D2A1, 4T1, EMT6, EO771, Py230), we found early loss of ductal myoepithelial cell differentiation markers p63, α-smooth muscle actin, and calponin, and rapid formation of IDC in the absence of DCIS. Rapid IDC formation also occurred in the absence of adaptive immunity. Combined, these studies demonstrate that loss of myoepithelial barrier function does not require an intact immune system, and suggest that these isogenic murine models may prove a useful tool to study IDC in the absence of a non-obligatory DCIS stage-an under-investigated subset of poor prognostic human breast cancer.

Studies of parenchymal texture added to mammographic breast density and risk of breast cancer: a systematic review of the methods used in the literature

This systematic review aimed to assess the methods used to classify mammographic breast parenchymal features in relation to the prediction of future breast cancer. The databases including Medline (Ovid) 1946-, Embase.com 1947-, CINAHL Plus 1937-, Scopus 1823-, Cochrane Library (including CENTRAL), and Clinicaltrials.gov were searched through October 2021 to extract published articles in English describing the relationship of parenchymal texture features with the risk of breast cancer. Twenty-eight articles published since 2016 were included in the final review. The identification of parenchymal texture features varied from using a predefined list to machine-driven identification. A reduction in the number of features chosen for subsequent analysis in relation to cancer incidence then varied across statistical approaches and machine learning methods. The variation in approach and number of features identified for inclusion in analysis precluded generating a quantitative summary or meta-analysis of the value of these features to improve predicting risk of future breast cancers. This updated overview of the state of the art revealed research gaps; based on these, we provide recommendations for future studies using parenchymal features for mammogram images to make use of accumulating image data, and external validation of prediction models that extend to 5 and 10 years to guide clinical risk management. Following these recommendations could enhance the applicability of models, helping improve risk classification and risk prediction for women to tailor screening and prevention strategies to the level of risk.

Contrast-enhanced spectral mammography without and with a delayed image for diagnosing malignancy among mass lesions in dense breast

Aim of the study

To analyse the diagnostic performance of contrast-enhanced spectral mammography (CESM) based on morphologic and enhancement patterns of mass lesions in dense breast using different protocols: CESM without delayed image and CESM with delayed image.

Material and methods

A total of 151 informed women with suspicious for malignancy mass lesions in dense breast were included in this study. All of them underwent CESM using 2 protocols. A total of 155 lesions were pathomorphologically verified. We analysed morphologic patterns on low-energy (LE) images and recombined images (RI) by defining the shape, margin, and dynamic patterns based on delayed images.

Results

The comparative analysis revealed that the shape and margins on RI were more significant than those on LE images. The dynamic indicators of CESM were found to be highly significant in dense breasts. The correlation between kinetic curve and histological results demonstrated that a persistent type of curve was common for benign lesions, accounting for 15/22 (68.1%); plateau and washout – for malignant lesions, accounting for 24/89 (26.9%) and 61/89 (68.5%), respectively. Delayed image leads to an increase of specificity up to 12.4%, which is statistically significant. The area under the curve (AUC) in CESM with delayed image is larger than that in CESM without delayed image (p < 0.01).

Conclusions

CESM is sensitive for the differential diagnosis of breast lesions. CESM with delayed image has higher specificity than CESM without delayed image. Delayed images with plateau and washout are typical for malignancy.

Which type of cancer is detected in breast screening programs? Review of the literature with focus on the most frequent histological features

Breast cancer is the most frequent type of cancer affecting female patients. The introduction of breast cancer screening programs led to a substantial reduction of mortality from breast cancer. Nevertheless, doubts are being raised on the real efficacy of breast screening programs. The aim of the present paper is to review the main pathological type of cancers detected in breast cancer screening programs. Specifically, attention will be given to: in situ carcinoma, invasive carcinoma histotypes and interval cancer.

Breast Cancer Screening in Asian Women with Dense Breast by Mammography: A Cross-Sectional Observational Study

Objective:

Mammography density of Asian women is known to be higher than Western women. After 2009, the Korean National Cancer Screening Program (NCSP) has started to notify mammography density (MD). To investigate the effect of MD notification, we integrated screening results with national health insurance claim data from 2009 to 2013.

Patients and Methods:

We performed a cross-sectional observational study which investigated the crude detection rate (CDR), positive predictive value (PPV), and incidence rate of Interval Cancer (IC). IC was defined as breast cancer, where the interval between the screening date and date of diagnosis was more than 12 months and less than 24 months among participants with previous normal results.

Results:

CDR and PPV per 100,000 results increased from 510.9 to 756.2 and from 1842.5 to 3364.9, respectively. The incidence rate of IC per 100,000 negative results increased from 623.3 to 676.2. Women younger than 50 years had a high incidence of ICs.

Conclusion:

After notifying MD, the incidence rate of IC less increased comparing with CDR or PPV. Screening mammography could be more useful to Asian women when reporting MD.

Comparison of Mortality Among Participants of Women's Health Initiative Trials With Screening-Detected Breast Cancers vs Interval Breast Cancers

IMPORTANCE

Interval breast cancers (IBCs) are cancers that emerge after a mammogram with negative results but before the patient's next scheduled screening. Interval breast cancer has a worse prognosis than cancers detected by screening; however, it is unknown whether the length of the interscreening period is associated with prognostic features and mortality.

OBJECTIVE

To compare the prognostic features and mortality rate of women with IBCs diagnosed within 1 year or between 1 and 2.5 years of a mammogram with negative results with the prognostic features and mortality rate of women with breast cancers detected by screening.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used mammography data, tumor characteristics, and patient demographic data from the Women's Health Initiative study, which recruited participants from 1993 to 1998 and followed up with participants for a median of 19 years. The present study sample for these analyses included women aged 50 to 79 years who participated in the Women's Health Initiative study and includes data collected through March 31, 2018. There were 5455 incidents of breast cancer; only 3019 women compliant with screening were retained in analyses. Statistical analysis was performed from October 25, 2018, to November 24, 2019. Breast cancers detected by screening and IBCs were defined based on mammogram history, date of last mammogram, type of visit, and results of examination. Interval breast cancers were subdivided into those occurring within 1 year or between 1 and 2.5 years after the last protocol-mandated mammogram with negative results.

MAIN OUTCOMES AND MEASURES

The primary outcome of this study was breast cancer-specific mortality for each case of breast cancer detected by screening and IBCs detected within 1 year or between 1 and 2.5 years from a mammogram with negative results. Secondary outcomes included prognostic and tumor characteristics for each group. Comparisons between groups were made using the t test, the χ2 test, and Fine-Gray multivariable cumulative incidence regression analyses.

RESULTS

Among the 3019 participants in this analysis, all were women with a mean (SD) age of 63.1 (6.8) years at enrollment and 68.5 (7.1) years at diagnosis. A total of 1050 cases of IBC were identified, with 324 (30.9%) diagnosed within 1 year from a mammogram with negative results and 726 (69.1%) diagnosed between 1 and 2.5 years after last mammogram with negative results. The remaining 1969 cases were breast cancers detected by screening. Interval breast cancers diagnosed within 1 year from a mammogram with negative results had significantly more lobular histologic characteristics (13.0% vs. 8.1%), a larger tumor size (1.97 cm vs 1.43 cm), a higher clinical stage (28.4% vs 17.3% regional and 3.7% vs 0.6% distant), and more lymph node involvement (27.1% vs 17.0%) than cancers detected by screening. Unadjusted breast cancer-specific mortality hazard ratios were significantly higher for IBCs diagnosed within 1 year from a mammogram with negative results compared with breast cancers detected by screening (hazard ratio, 1.92; 95% CI, 1.39-2.65). Higher breast cancer-specific mortality remained statistically significant for IBCs diagnosed within 1 year after adjusting for trial group, molecular subtype, waist to hip ratio, histologic characteristics, and either tumor size (hazard ratio, 1.46; 95% CI, 1.03-2.08) or lymph node involvement (hazard ratio, 1.44; 95% CI, 1.03-2.01). However, significance was lost when tumor size and lymph node involvement were both included in the model (hazard ratio, 1.34; 95% CI, 0.96-1.88). Interval breast cancers diagnosed between 1 and 2.5 years from a mammogram with negative results were not different from breast cancers detected by screening based on prognostic factors or mortality.

CONCLUSIONS AND RELEVANCE

Women with IBCs diagnosed within 1 year of negative mammogram results overall were associated with worse survival than women with breast cancers detected by screening. These differences in survival may be due to a uniquely aggressive biology among IBC cases.

Current Resources for Evidence-Based Practice, November 2019

A review of new resources to support the provision of evidence-based care for women and infants.

Interval Breast Cancer Versus Screen-Detected Cancer: Comparison of Clinicopathologic Characteristics in a Single-Center Analysis

BACKGROUND

The introduction of breast screening programs has raised the problem of interval breast cancers (IBC). The aims of this study were to analyze the impact of IBC on the screening program, to compare IBC and screen-detected cancers (SDC), and to identify possible predictors of mortality.

PATIENTS AND METHODS

Patients with breast cancer diagnosed during the regional breast screening program between January 2008 and December 2013 at a single center in Italy were included. Demographic, preoperative, and postoperative data were prospectively collected and retrospectively analyzed.

RESULTS

Five hundred thirty-four patients were enrolled; 106 women (19.9%) had IBC and 428 women (80.1%) SDC. IBC presented more aggressive features compared to SDC, such as tumor invasiveness (95% vs. 85%; P = .005), tumor size (≥ pT2 37% vs. 21%; P = .001), grade (G3 39% vs. 17%; P < .001), and St Gallen molecular subtype (triple negative 22% vs. 7%; P < .001), resulting in higher distant recurrence rate (8% vs. 2%; P = .009) and worse overall and disease-free survival (P = .03 and P = .001, respectively). Cox multivariate regression analysis identified St Gallen molecular subtype as the only predictor of mortality in patients with breast cancer (P = .03).

CONCLUSION

IBC accounted for one-fifth of all breast cancers diagnosed in women who followed the regional screening program. Furthermore, IBC appeared to have more aggressive features compared to SDC, leading to worse survival. These worse survivals depended on St Gallen molecular subtype.

Retrospective observation on contribution and limitations of screening for breast cancer with mammography in Korea: detection rate of breast cancer and incidence rate of interval cancer of the breast

Background

The purpose of this study was to determine the benefits and limitations of screening for breast cancer using mammography.

Methods

Descriptive design with follow-up was used in the study. Data from breast cancer screening and health insurance claim data were used. The study population consisted of all participants in breast cancer screening from 2009 to 2014. Crude detection rate, positive predictive value and sensitivity and specificity of breast cancer screening and, incidence rate of interval cancer of the breast were calculated.

Results

The crude detection rate of breast cancer screening per 100,000 participants increased from 126.3 in 2009 to 182.1 in 2014. The positive predictive value of breast cancer screening per 100,000 positives increased from 741.2 in 2009 to 1,367.9 in 2014. The incidence rate of interval cancer of the breast per 100,000 negatives increased from 51.7 in 2009 to 76.3 in 2014. The sensitivities of screening for breast cancer were 74.6% in 2009 and 75.1% in 2014 and the specificities were 83.1% in 2009 and 85.7% in 2014.

Conclusions

To increase the detection rate of breast cancer by breast cancer screening using mammography, the participation rate should be higher and an environment where accurate mammography and reading can be performed and reinforcement of quality control are required. To reduce the incidence rate of interval cancer of the breast, it will be necessary to educate women after their 20s to perform self-examination of the breast once a month regardless of participation in screening for breast cancer.

Application of imaging mass spectrometry for the molecular diagnosis of human breast tumors

Distinguishing breast invasive ductal carcinoma (IDC) and breast ductal carcinoma in situ (DCIS) is a key step in breast surgery, especially to determine whether DCIS is associated with tumor cell micro-invasion. However, there is currently no reliable method to obtain molecular information for breast tumor analysis during surgery. Here, we present a novel air flow-assisted ionization (AFAI) mass spectrometry imaging method that can be used in ambient environments to differentiate breast cancer by analyzing lipids. In this study, we demonstrate that various subtypes and histological grades of IDC and DCIS can be discriminated using AFAI-MSI: phospholipids were more abundant in IDC than in DCIS, whereas fatty acids were more abundant in DCIS than in IDC. The classification of specimens in the subtype and grade validation sets showed 100% and 78.6% agreement with the histopathological diagnosis, respectively. Our work shows the rapid classification of breast cancer utilizing AFAI-MSI. This work suggests that this method could be developed to provide surgeons with nearly real-time information to guide surgical resections.