Will supplemental screening ultrasound increase breast cancer overdiagnosis?

Attitudes of Gynecologists toward Referral of Women to Breast Imaging Clinics for Breast Cancer Screening or Diagnosis

PURPOSE

To investigate whether gynecologists considered the age of women when requesting ultrasound (US) and/or mammography examinations. Furthermore, to determine in which situations gynecologists referred patients to breast imaging clinics for breast examinations, and aimed to establish the reasons behind cases of non-referral.

MATERIALS AND METHODS

A questionnaire-based survey was conducted from February to April 2023 among gynecologists practicing at government, university, or private hospitals/centers. The participants were contacted through an online Web link ( www.googledocs.com ).

RESULTS

The questionnaire was completed by 80 gynecologists. In total, 96.2% of the participants referred women to breast imaging clinics. The proportion of female physicians (70%) was higher than that of male physicians, and 55% were younger than 40 years. Menopause, hormone replacement therapy, and hereditary/genetic or familial breast cancer were the most commonly considered risk factors when referring women. Overall, 75% of participants requested mammography for women aged ≥ 40 years. For women between the ages of 30 and 40, mammography was requested by 40% of physicians. For women younger than 30, US was requested by 70% of participants, while a small number of participants (7.5%) requested mammography if deemed necessary.

CONCLUSION

Gynecologists tend to refer women to breast imaging clinics for screening rather than for diagnostic purposes. Female gynecologists have a higher tendency for referral, especially if there is a risk factor involved. Seminars or courses at gynecology conferences can be organized by experienced breast imaging specialists to give detailed information about breast cancer and examination methods according to patient age. This will ensure better breast assessment.

Association Between Dense Breast Legislation and Cancer Stage at Diagnosis

INTRODUCTION

Many states have mandated breast density notification and insurance coverage for additional screening; yet, the association between such legislation and stage of diagnosis for breast cancer is unclear. This study investigates this association and examines the differential impacts among different age and race/ethnicity subgroups.

METHODS

The Surveillance, Epidemiology, and End Results database was queried to identify patients with breast cancer aged 40-74 years diagnosed between 2005 and 2016. Using a difference-in-differences multinomial logistic model, the odds of being diagnosed at different stages of cancer relative to the localized stage depending on legislation and individual characteristics were examined. Analyses were conducted in 2020-2021.

RESULTS

The study included 689,641 cases. Overall, the impact of notification legislation was not significant, whereas insurance coverage legislation was associated with 6% lower odds (OR=0.94, 95% CI=0.91, 0.96) of being diagnosed at the regional stage. The association between insurance coverage legislation and stage of diagnosis was even stronger among women aged 40-49 years, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.96) of being diagnosed at the regional stage and 12% lower odds (OR=0.88, 95% CI=0.81, 0.96) of being diagnosed at the distant stage. Hispanic women benefited from notification laws, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.97) of being diagnosed at distant stage. Neither notification nor supplemental screening insurance coverage legislation showed a substantial impact on Black women.

CONCLUSIONS

The findings imply that improving insurance coverage is more important than being notified overall. Raising awareness is important among Hispanic women; improving communication about dense breasts and access to screening might be more important than legislation among Black women.

Overall assessment system of combined mammography and ultrasound for breast cancer screening in Japan

Mammography is the only screening method with evidence in support of reduced breast cancer mortality, but yields poor accuracy outcomes in women with dense breast tissue. The Japan Strategic Anti-cancer Randomized Trial (J-START) was conducted as part of the measures implemented to deal with women with dense breast tissue. Although the sensitivity was increased, the specificity was significantly lower in the intervention group because further examination was required in all positive cases classified by either mammography or ultrasound in the J-START. To address the issue, an overall assessment system of combined mammography and adjunctive ultrasound for breast cancer screening has been developed in Japan. The basic concept is based on a comprehensive assessment that includes a mammography assessment followed by an adjunctive assessment for ultrasound similar to the clinical setting. Currently, mammography alone is recommended for population-based breast cancer screening in Japan, but additional ultrasonography is extensively available for women, especially for women with dense breasts with shared decision-making for personalized breast cancer screening. The overall assessment system is recommended for use in Japan when breast cancer screening is conducted using both mammography and ultrasonography. In this article, we summarize the advantages of the overall assessment and the simultaneous mammography/ultrasound method, the basic approach used in Japan to assign the overall assessment category for breast cancer screening, and we outline the future directions of adjunctive screening ultrasound.

Clinicopathological characteristics and long-term prognosis of screening detected non-palpable breast cancer by ultrasound in hospital-based Chinese population (2001-2014)

Purpose

The mainstay modality of breast cancer screening in China is the hospital-based opportunistic screening among asymptomatic self-referred women. There is little data about the ultrasound (US) detected non-palpable breast cancer (NPBC) in Chinese population.

Methods

We analyzed 699 consecutive NPBC from 1.8-2.3 million asymptomatic women from 2001 to 2014, including 572 US-detected NPBC from 3,786 US-positive women and 127 mammography (MG) detected NPBC from 788 MG-positive women. The clinicopathological features, disease-free survival (DFS) and overall survival (OS) were compared between the US- and MG-detected NPBC. Prognostic factors of NPBC were identified.

Results

Compared to MG, US could detect more invasive NPBC (83.6% vs 54.3%, p<0.001), lymph node positive NPBC (19.1% vs 10.2%, p=0.018), lower grade (24.8% vs 16.5%, p<0.001), multifocal (19.2% vs 6.3%, p<0.001), PR positive (71.4% vs 66.9%, p=0.041), Her2 negative (74.3% vs 54.3%, p<0.001), Ki67 high (defined as >14%, 46.3% vs 37.0%, p=0.031) cancers and more NPBC who received chemotherapy (40.7% vs 21.3%, p<0.001). There was no significant difference in 10-year DFS and OS between US-detected vs MG-detected NPBC, DCIS and invasive NPBC. For all NPBC and the US-detected NPBC, the common DFS-predictors included pT, pN, p53 and bilateral cancers.

Conclusion

US could detect more invasive, node-positive, multifocal NPBC in hospital-based asymptomatic Chinese female, who could achieve comparable 10-year DFS and OS as MG-detected NPBC. US would not delay early detection of NPBC with improved cost-effectiveness, thus could serve as the feasible initial imaging modality in hospital-based opportunistic screening among Chinese women.

Synergy in combining findings from mammography and ultrasonography in detecting malignancy in women with higher density breasts and lesions over 2 cm in Albania

AIM OF THE STUDY

To provide evidence of the synergy of combining findings from mammography (MM) and ultrasonography (US) in detecting malignancy in women with high-density breasts.

MATERIAL AND METHODS

A total of 245 women were screened for breast cancer using both mammography and ultrasonography at the American Hospital in Tirana during 2013-2014. The data was used to identify possible benefits in detecting malignancy, by combining the findings of MM and US and confirming them with those of the biopsy. Data on age, breast density, BI-RADS classification, and biopsy confirmations were collected and analysed.

RESULTS

Out of the 245 women, 36 biopsies were taken (17 for women classified BI-RADS 4 and 5; 19 for women with BI-RADS 3 that had grown in size from the previous examination). The accuracy in detecting malignancy for low-density-breast women was 90% for MM, 70% for US, and 90% for combined. For high-density breasts, the accuracy was 65% for MM, 79% for US, and 82% for combined findings. Multivariate analysis indicates that high-density-breast women who have a malignant finding in at least one of the examinations (MM or US) are 24 times more likely (p = 0.039) to have a positive finding in biopsy for malignancy. The odds increased 32 times for lesions over 2 cm (p = 0.056).

CONCLUSIONS

Our study results indicate additional benefits of combining findings from MM and US for high-density-breast women. Further study is warranted in a larger population and for different kinds of cancer.

Implications of Overdiagnosis: Impact on Screening Mammography Practices

This review article explores the issue of overdiagnosis in screening mammography. Overdiagnosis is the screen detection of a breast cancer, histologically confirmed, that might not otherwise become clinically apparent during the lifetime of the patient. While screening mammography is an imperfect tool, it remains the best tool we have to diagnose breast cancer early, before a patient is symptomatic and at a time when chances of survival and options for treatment are most favorable. In 2015, an estimated 231,840 new cases of breast cancer (excluding ductal carcinoma in situ) will be diagnosed in the United States, and some 40,290 women will die. Despite these data, screening mammography for women ages 40-69 has contributed to a substantial reduction in breast cancer mortality, and organized screening programs have led to a shift from late-stage diagnosis to early-stage detection. Current estimates of overdiagnosis in screening mammography vary widely, from 0% to upwards of 30% of diagnosed cancers. This range reflects the fact that measuring overdiagnosis is not a straightforward calculation, but usually one based on different sets of assumptions and often biased by methodological flaws. The recent development of tomosynthesis, which creates high-resolution, three-dimensional images, has increased breast cancer detection while reducing false recalls. Because the greatest harm of overdiagnosis is overtreatment, the key goal should not be less diagnosis but better treatment decision tools. (Population Health Management 2015;18:S3-S11).