ACR Appropriateness Criteria Breast Cancer Screening

Clinical guidelines for the management of mammographic density: a systematic review of breast screening guidelines worldwide

BACKGROUND

High breast density is an independent risk factor for breast cancer and decreases the sensitivity of mammography. This systematic review synthesizes the international clinical guidelines and the evidence base for screening and supplemental screening recommendations in women with dense breasts.

METHODS

A systematic search of CINHAL, Embase, and Medline databases was performed in August 2023 and grey literature searched in January 2024. Two authors independently assessed study eligibility and quality (Appraisal of Guidelines for Research and Evaluation II instrument).

RESULTS

Of 3809 articles, 23 guidelines published from 2014 to 2024 were included. The content and quality varied between the guidelines; the average AGREE II total score was 58% (range = 23%-87%). Most guidelines recommended annual or biennial screening mammography for women more than 40 years old with dense breasts (n = 16). Other guidelines recommended breast tomosynthesis (DBT, n = 6) or magnetic resonance imaging (MRI, n = 1) as the preferred screening modality. One third of the guidelines (n = 8) did not recommend supplemental screening for women with dense breasts. Of those that recommended supplemental screening (n = 14), ultrasound was the preferred modality (n = 7), with MRI (n = 3), DBT (n = 3), and contrast-enhanced mammography (n = 2) also recommended.

CONCLUSIONS

Consensus on supplemental screening in women with dense breasts is lacking. The quality of the guidelines is variable, and recommendations are based largely on low-quality evidence. As evidence of the benefits versus harms of supplemental screening in women with dense breasts is evolving, it is imperative to improve the methodological quality of breast cancer screening and supplemental screening guidelines.

Breast Imaging Physics in Mammography (Part I)

Breast cancer is the most frequently diagnosed neoplasm in women in Italy. There are several risk factors, but thanks to screening and increased awareness, most breast cancers are diagnosed at an early stage when surgical treatment can most often be conservative and the adopted therapy is more effective. Regular screening is essential but advanced technology is needed to achieve quality diagnoses. Mammography is the gold standard for early detection of breast cancer. It is a specialized technique for detecting breast cancer and, thus, distinguishing normal tissue from cancerous breast tissue. Mammography techniques are based on physical principles: through the proper use of X-rays, the structures of different tissues can be observed. This first part of the paper attempts to explain the physical principles used in mammography. In particular, we will see how a mammogram is composed and what physical principles are used to obtain diagnostic images.

Clinicopathological Factors Affecting Breast Cancer Survival in Jamaican Women: A Retrospective Review

OBJECTIVE

Breast cancer is the leading cause of cancer affecting women worldwide. The survival rate is primarily affected by the stage of the disease and several other demographic and clinicopathological factors.

METHODS

This study is a retrospective cohort study of female patients of the University Hospital of the West Indies diagnosed with breast cancer between 2011 and 2016. The age, tumor size, SBR/Nottingham grade, tumor histologic subtype, tumor molecular subtype, and survival status of the cohort on November 1, 2019, were determined. The data were summarized. Survival across each variable was compared using univariate log-rank tests, Cox proportional hazard models, and crude and adjusted models. A second wave analysis was performed excluding patients whose survival status was presumed.

RESULTS

A total of 503 patients were analyzed. The overall survival rate at 1, 3, and 5 years were 96.4%, 84.9%, and 79.0%, respectively, for the entire cohort. The molecular subtype was the most significant clinicopathological factor affecting overall survival. A younger age < 40 years, higher histologic grade, estrogen receptor-negative breast cancers, invasive ductal type breast cancers, and T1 lesions were associated with poorer survival outcomes at 5 years. The findings were reproduced after a second wave analysis excluding patients who were presumed alive was applied.

CONCLUSIONS

Breast cancer overall survival in Jamaica is consistent with that of other developing countries in the literature. This study is an important contribution to the growing body of literature available and aids to the overall understanding of the behavior of breast cancer locally.

Young Black Women May be More Likely to Have First Mammogram Cancers: A New Perspective in Breast Cancer Disparities

INTRODUCTION

Black women are diagnosed with breast cancer at earlier ages and are 42% more likely to die from the disease than White women. Recommendations for commencement of screening mammography remain discordant. This study sought to determine the frequency of first mammogram cancers among Black women versus other self-reported racial groups.

METHODS

In this retrospective cohort study, clinical and mammographic data were obtained from 738 women aged 40-45 years who underwent treatment for breast cancer between 2010 and 2019 within a single hospital system. First mammogram cancers were defined as those with tissue diagnoses within 3 months of baseline mammogram. Multivariate logistic regression was applied to assess variables associated with first mammogram cancer detection.

RESULTS

Black women were significantly more likely to have first mammogram cancer diagnoses (39/82, 47.6%) compared with White women (162/610, 26.6%) and other groups (16/46, 34.8%) [p < 0.001]. Black women were also more likely to have a body mass index > 30 (p < 0.001), higher clinical T categories (p = 0.02), and present with more advanced clinical stages (p = 0.03). Every month delay in mammographic screening beyond age 40 years (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.05-1.07; p < 0.0001), Black race (OR 2.24, 95% CI 1.10-4.53; p = 0.03), and lack of private insurance (OR 2.41, 95% CI 1.22-4.73; p = 0.01) were associated with an increased likelihood of cancer detection on first mammogram.

CONCLUSION

Our findings suggests that Black women aged 40-45 years may be more likely to have cancer detected on their first mammogram and would benefit from starting screening mammography no later than age 40 years, and for those with elevated lifetime risk, even sooner.

Does MRI have added value in ultrasound-detected BIRADS-3 breast masses in candidates for assisted reproductive therapy?

Background

Ultrasound-detected breast lesions with probably benign features are a great challenge for clinicians, especially in breasts with dense composition. We aimed to investigate the finding of two radiologic modalities on these lesions.

Methods

This retrospective cross-sectional study recruited patients including (1) candidates of assisted reproductive therapy (ART), (2) patients with prior high-risk lesions, and (3) the "suspected" BIRADS-3 masses referring to masses that US BIRADS-3 was not compatible with the clinical breast exam. The degree of agreement in diagnosing BIRADS-3 lesions between two modalities of magnetic resonance imaging (MRI) and ultrasonography (US), and comparison of the lesions in US and MRI were the study variables.

Results

A total number of 123 lesions in 67 patients with a median age of 38 (IQR: 11, range: 17-67). In the examination by MRI, 107 (87.0 %) lesions were BIRADS-3 indicating the agreement level between these two modalities. The median size of the lesions in US was 9 mm (IQR: 5, range: 3-43) and 9 mm (IQR: 10, range: 4-46) in MRI. The measured size of the lesions between the two modalities was highly correlated (Spearman correlation coefficient: 0.889, P-value < 0.001). MRI evaluation revealed two cases of deep lesions which were missed in the US imaging.

Conclusions

This study found relatively high agreement values between US and MRI in detecting BIRADS-3 breast lesions in candidates for ART or patients with prior high-risk lesions. Also, MRI could downgrade about one-tenth of the cases to a lower BIRADS level and resolved the need for closer follow-up.

Detection of breast cancer by ATR-FTIR spectroscopy using artificial neural networks

In this study, three (3) neural networks (NN) were designed to discriminate between malignant (n = 78) and benign (n = 88) breast tumors using their respective attenuated total reflection Fourier transform infrared (ATR-FTIR) spectral data. A proposed NN-based sensitivity analysis was performed to determine the most significant IR regions that distinguished benign from malignant samples. The result of the NN-based sensitivity analysis was compared to the obtained results from FTIR visual peak identification. In training each NN models, a 10-fold cross validation was performed and the performance metrics-area under the curve (AUC), accuracy, positive predictive value (PPV), specificity rate (SR), negative predictive value (NPV), and recall rate (RR)-were averaged for comparison. The NN models were compared to six (6) machine learning models-logistic regression (LR), Naïve Bayes (NB), decision trees (DT), random forest (RF), support vector machine (SVM) and linear discriminant analysis (LDA)-for benchmarking. The NN models were able to outperform the LR, NB, DT, RF, and LDA for all metrics; while only surpassing the SVM in accuracy, NPV and SR. The best performance metric among the NN models was 90.48% ± 10.30% for AUC, 96.06% ± 7.07% for ACC, 92.18 ± 11.88% for PPV, 94.19 ± 10.57% for NPV, 89.04% ± 16.75% for SR, and 94.34% ± 10.54% for RR. Results from the proposed sensitivity analysis were consistent with the visual peak identification. However, unlike the FTIR visual peak identification method, the NN-based method identified the IR region associated with C-OH C-OH group carbohydrates as significant. IR regions associated with amino acids and amide proteins were also determined as possible sources of variability. In conclusion, results show that ATR-FTIR via NN is a potential diagnostic tool. This study also suggests a possible more specific method in determining relevant regions within a sample's spectrum using NN.

Breast cancer risk reduction: who, why, and what?

Women at increased risk of breast cancer have options to mitigate that risk. Understanding factors that increase risk and utilizing tools for quantitative estimates are important to be able to adequately counsel and target strategies for patients. On the basis of these estimates, patients may be able to engage in risk reduction interventions and increased screening, including chemoprevention or surgical risk reduction. Multiple organizations have published guidelines supporting risk assessment, genetic assessment, increased screening, and prevention measures for these women.

Influence of Menopausal Hormone Therapy on the Breast: Counseling Your Patients Before You Prescribe

Menopausal hormone therapy (HT) aims to improve a woman's quality of life by treating bothersome menopausal symptoms associated with low estrogen levels. Although HT is prescribed to millions of women worldwide, its breast-related adverse effects have always been a concern. Some of the common adverse effects of HT are breast fullness, increased breast density, and increased breast cancer (BC) risk. Health care professionals need to be aware of the influence of HT on breast tissue to provide appropriate counseling as part of informed decision making. Our review summarizes the influence of HT on breast symptoms, breast density, mammograms, and BC risk.

Supplemental Cancer Screening for Women With Dense Breasts: Guidance for Health Care Professionals

Mammography is the standard for breast cancer screening. The sensitivity of mammography in identifying breast cancer, however, is reduced for women with dense breasts. Thirty-eight states have passed laws requiring that all women be notified of breast tissue density results in their mammogram report. The notification includes a statement that differs by state, encouraging women to discuss supplemental screening options with their health care professionals (HCPs). Several supplemental screening tests are available for women with dense breast tissue, but no established guidelines exist to direct HCPs in their recommendation of preferred supplemental screening test. Tailored screening, which takes into consideration the patient's mammographic breast density and lifetime breast cancer risk, can guide breast cancer screening strategies that are more comprehensive. This review describes the benefits and limitations of the various available supplemental screening tests to guide HCPs and patients in choosing the appropriate breast cancer screening.

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.

Breast cancer in women under age 40: A decade of trend analysis at a single institution

BACKGROUND

Women should be evaluated for breast cancer risk by age 30 to assess for screening need. Recent trends in breast cancer in this population may further inform recommendations.

OBJECTIVE

The aim of this study was to analyze trends over time in the rate of breast cancer, tumor characteristics and treatment in women under age 40.

METHODS

Retrospective cohort study of women under age 40 at our institution diagnosed with breast cancer from January 2007 to April 2018 was conducted. Patient demographics, tumor characteristics and treatment outcomes were collected. Descriptive statistics and the Mann-Kendell Trend test were calculated. Two-proportion z-tests were used to compare proportions of stage, pathology and treatment between 2007-2013 and 2014-2018.

RESULTS

197 women under age 40 were treated for a new diagnosis of breast cancer at our institution. A higher proportion of women were diagnosed with invasive carcinoma in 2013-2018 (91%) compared to 2007-2012 (78%), p = 0.008. A higher proportion of women were diagnosed with advanced stage disease (stage III-IV) in 2013-2018 (24%) compared to 2007-2012 (2%), p = 0.001. No statistically significant evidence for an increasing trend of overall rate of breast cancer over the last 11 years (p = 0.419) was observed.

CONCLUSIONS

While no statistically significant increase in overall rate of breast cancer was noted, an increase in invasive and later staged breast cancers was observed.

CLINICAL IMPACT

Rise in more aggressive cancers in a population that is largely not screened may have implications both on the individual young woman's morbidity as well as on a public health level.

Breast cancer, screening and diagnostic tools: All you need to know

Breast cancer is one of the most frequent malignancies among women worldwide. Methods for screening and diagnosis allow health care professionals to provide personalized treatments that improve the outcome and survival. Scientists and physicians are working side-by-side to develop evidence-based guidelines and equipment to detect cancer earlier. However, the lack of comprehensive interdisciplinary information and understanding between biomedical, medical, and technology professionals makes innovation of new screening and diagnosis tools difficult. This critical review gathers, for the first time, information concerning normal breast and cancer biology, established and emerging methods for screening and diagnosis, staging and grading, molecular and genetic biomarkers. Our purpose is to address key interdisciplinary information about these methods for physicians and scientists. Only the multidisciplinary interaction and communication between scientists, health care professionals, technical experts and patients will lead to the development of better detection tools and methods for an improved screening and early diagnosis.

Screening in patients with increased risk of breast cancer (part 2). Where are we now? Actual MRI screening controversies

For women with a high risk of breast cancer, early detection plays an important role. Due to the high incidence of breast cancer, and at a younger age than in the general population, screening begins earlier, and there is considerable evidence that magnetic resonance is the most sensitive diagnostic tool, and the principal American and European guidelines agree on the recommendation to perform annual magnetic resonance (with supplemental annual mammography) as an optimal mode of screening. In addition to the absence of current consensus on which patients should be included in the recommendation for magnetic resonance screening (widely discussed in the introduction of part 1 of this work), there are other aspects that are different between guidelines, that are not specified, or that are susceptible to change based on the evidence of several years of experience, that we have called «controversies», such as the age to begin screening, the possible advisability of using a different strategy in different subgroups, performing alternate versus synchronous magnetic resonance and mammography, the age at which to terminate the two techniques, or how to follow up after risk reduction surgery.The aim of the second part of the paper is, by reviewing the literature, to provide an update in relation to some of the main «controversies» in high risk screening with magnetic resonance. And finally, based on all this, to propose a possible model of optimal and updated screening protocol.

Surveillance for second breast cancer events in women with a personal history of breast cancer using breast MRI: a systematic review and meta-analysis

PURPOSE

Women with personal history of breast cancer (PHBC) are currently recommended to receive annual mammography for surveillance of breast cancer recurrence or new primary. However, given issues in accuracy with mammography, there is a need for evolving evidence-based surveillance recommendations with supplemental imaging. In this systematic review, we compiled and compared existing studies that describe the test performance of surveillance breast MRI among women with PHBC.

METHODS

We searched PubMed and EMBASE using MeSH terms for studies (2000-2019) that described the diagnostic characteristics of breast MRI in women with PHBC. Search results were reviewed and included based on PICOTS criteria; quality of included articles was assessed using QUADAS-2. Meta-analysis of single proportions was conducted for diagnostic characteristics of breast MRI, including tests of heterogeneity.

RESULTS

Our review included 11 articles in which unique cohorts were studied, comprised of a total of 8338 women with PHBC and 12,335 breast MRI done for the purpose of surveillance. We predict intervals (PI) for cancer detection rate per 1000 examinations (PI 9-15; I² = 10%), recall rate (PI 5-31%; I² = 97%), sensitivity (PI 58-95%; I² = 47%), specificity (PI 76-97%; I² = 97%), and PPV3 (PI 16-40%; I² = 44%).

CONCLUSIONS

Studies addressing performance of breast MRI are variable and limited in population-based studies. The summary of evidence to date is insufficient to recommend for or against use of breast MRI for surveillance among women with PHBC.

Survival Outcomes of Screening with Breast MRI in Women at Elevated Risk of Breast Cancer

Objective

To determine survival outcomes in women with breast cancer detected at combined screening with breast MRI and mammography versus screening mammography alone.

Methods

This is an institutional review board-approved retrospective study, and the need for informed consent was waived. A total of 3002 women with an increased risk of breast cancer were screened between 2001 and 2004. Of the 3002 women, 1534 (51.1%) had 2780 combined screenings (MRI and mammography) and 1468 (48.9%) had 4811 mammography-only screenings. The Χ ² test and the Kaplan-Meier method were used to compare cancer detection rates and survival rates.

Results

The overall cancer detection rate was significantly higher in the MRI plus mammography group compared with the mammography-only group (1.4% [40 of 2780] vs 0.5% [23 of 4811]; P < 0.001). No interval cancers occurred in the MRI plus mammography group, whereas 9 interval cancers were found in the mammography-only group. During a median follow-up of 10.9 years (range: 0.7 to 15.2), a total of 11 recurrences and 5 deaths occurred. Of the 11 recurrences, 6 were in the MRI plus mammography group and 5 were in the mammography-only group. All five deaths occurred in the mammography-only group. Disease-free survival showed no statistically significant difference between the two groups (P = 0.32). However, overall survival was significantly improved in the MRI plus mammography group (P = 0.002).

Conclusion

Combined screening with MRI and mammography in women at elevated risk of breast cancer improves cancer detection and overall survival.

Radiomic nomogram for prediction of axillary lymph node metastasis in breast cancer

OBJECTIVE

To develop a radiomic nomogram for preoperative prediction of axillary lymph node (LN) metastasis in breast cancer patients.

METHODS

Preoperative magnetic resonance imaging data from 411 breast cancer patients was studied. Patients were assigned to either a training cohort (n = 279) or a validation cohort (n = 132). Eight hundred eight radiomic features were extracted from the first phase of T1-DCE images. A support vector machine was used to develop a radiomic signature, and logistic regression was used to develop a nomogram.

RESULTS

The radiomic signature based on 12 LN status-related features was constructed to predict LN metastasis, its prediction ability was moderate, with an area under the curve (AUC) of 0.76 and 0.78 in training and validation cohorts, respectively. Based on a radiomic signature and clinical features, a nomogram was developed and showed excellent predictive ability for LN metastasis (AUC 0.84 and 0.87 in training and validation sets, respectively). Another radiomic signature was constructed to distinguish the number of metastatic LNs (less than 2 positive nodes/more than 2 positive nodes), which also showed moderate performance (AUC 0.79).

CONCLUSIONS

We developed a nomogram and a radiomic signature that can be used to identify LN metastasis and distinguish the number of metastatic LNs (less than 2 positive nodes/more than 2 positive nodes). Both nomogram and radiomic signature can be used as tools to assist clinicians in assessing LN metastasis in breast cancer patients.

KEY POINTS

• ALNM is an important factor affecting breast cancer patients' treatment and prognosis. • Traditional imaging examinations have limited value for evaluating axillary LNs status. • We developed a radiomic nomogram based on MR imagings to predict LN metastasis.

Breast MRI screening for average-risk women: A monte carlo simulation cost-benefit analysis

BACKGROUND

Screening high-risk women for breast cancer with MRI is cost-effective, with increasing cost-effectiveness paralleling increasing risk. However, for average-risk women cost is considered a major limitation to mass screening with MRI.

PURPOSE

To perform a cost-benefit analysis of a simulated breast cancer screening program for average-risk women comparing MRI with mammography.

STUDY TYPE

Population simulation study.

POPULATION/SUBJECTS

Five million (M) hypothetical women undergoing breast cancer screening.

FIELD STRENGTH/SEQUENCE

Simulation based primarily on Kuhl et al8 study utilizing 1.5T MRI with an axial bilateral 2D multisection gradient-echo dynamic series (repetition time / echo time 250/4.6 msec; flip angle, 90°) with a full 512 × 512 acquisition matrix and a sensitivity encoding factor of two, performed prior to and four times after bolus injection of 0.1 mmol of gadobutrol per kg of body weight (Gadovist; Bayer, Germany). An axial T2 -weighted fast spin-echo sequence with identical anatomic parameters was also included.

ASSESSMENT

A Monte Carlo simulation utilizing Medicare reimbursement rates to calculate input variable costs was developed to compare 5M women undergoing breast cancer screening with either triennial MRI or annual mammography, 2.5M in each group, over 30 years.

STATISTICAL TESTS

Expected recall rates, BI-RADS 3, BI-RADS 4/5 cases and cancer detection rates were determined from published literature with calculated aggregate costs including resultant diagnostic/follow-up imaging and biopsies.

RESULTS

Baseline screening of 2.5M women with breast MRI cost $1.6 billion (B), 3× higher than baseline mammography screening ($0.54B). With subsequent screening, MRI screening is more cost-effective than mammography screening in 24 years ($13.02B vs. $13.03B). MRI screening program costs are largely driven by cost per MRI exam ($549.71). A second simulation model was performed based on MRI Medicare reimbursement trends using a lower MRI cost ($400). This yielded a cost-effective benefit compared to mammography screening in less than 6 years ($3.41B vs. $3.65B), with over a 22% cost reduction relative to mammography screening in 12 years and reaching a 38% reduction in 30 years.

DATA CONCLUSION

Despite higher initial cost of a breast MRI screening program for average-risk women, there is ultimately a cost savings over time compared with mammography. This estimate is conservative given cost-benefit of additional/earlier breast cancers detected by breast MRI were not accounted for.

LEVEL OF EVIDENCE

3 Technical Efficacy Stage: 6 J. Magn. Reson. Imaging 2019.

Breast MRI ordering practices in a large health care network

The purpose of this study was to evaluate providers' ordering practices and perceptions of breast magnetic resonance imaging (MRI) in an academic network in order to better understand and educate a referral base. An online survey was distributed to primary care providers (PCPs) and specialists in our hospital and community practices. Questions included provider demographics, current ordering practices, challenges to ordering, and perceptions about breast MRI. Of 525 ordering providers, 134 responded (26% response rate). Of 134 providers, 57 (42%) order breast MRI in practice. Of those who do not, the most consistent reason was a lack of familiarity with the use of breast MRI (32/77 [42%] of cases). Of 57 cases, 45 (79%) order less than 10 exams annually. The most frequent indication is for high-risk screening (40/47 [84%]). PCPs order fewer breast MRI compared with specialists (P = 0.01). Both PCPs and specialists have mixed perceptions of the clinical utility of breast MRI. However, 30% of all providers are ordering more breast MRI since the enactment of breast density legislation in Massachusetts. Furthermore, 29% report they would order breast MRI more often to screen women with dense breasts if there was a low cost option. Referring provider surveys are useful tools for assessing a radiology practice. Our study suggests a growing clinical interest in breast MRI for screening; however, there is a need for provider education on the clinical utility of breast MRI. Increasing the radiologist's role in targeted educational interventions may help improve awareness and lead to more appropriate utilization of resources.

Breast Cancer Incidence by Stage Before and After Change in Screening Guidelines

INTRODUCTION

The U.S. Preventive Services Task Force changed breast cancer screening guidelines in November 2009 for mammograms in women aged 40-49 and 50-74 years. The aim of this study was to assess the impact of the 2009 guideline changes on breast cancer incidence by stage among women aged 40-49 and 50-74 years in the U.S.

METHODS

This was a cross-sectional trend analysis of the impact of 2009 guideline change on breast cancer incidence by stage, using data from the National Program for Cancer Registries and Surveillance, Epidemiology, and End Results Incidence-U.S. Cancer Statistics 2001-2014 database among women aged 40-74 years. Incidence was age adjusted to the U.S. standard population. Data were collected in 2001-2014, released in 2017, and analyzed in 2018.

RESULTS

Among women aged 40-49 years, the 4-year average annual incidence of breast cancer increased slightly in 2011-2014 for in situ, localized, and distant cancer, but decreased for regional cancer compared with the incidence in 2006-2009. Among women aged 50-74 years, the 4-year average annual incidence of breast cancer increased in 2011-2014 for localized and distant cancer, but decreased for in situ and regional cancer. Joinpoint analyses revealed that annual percentage changes decreased after 2009 for distant cancer among both women aged 40-49 and 50-74 years. The composition of breast cancer by stage was similar between 2006-2009 and 2011-2014 among both women aged 40-49 and 50-74 years.

CONCLUSIONS

Changes in breast cancer screening by the 2009 U.S. Preventive Services Task Force guidelines had little immediate adverse effects on the stage distribution of breast cancer diagnoses in the U.S. Monitoring the incidence by cancer stages over time is needed.

Breast ultrasonography (BU) in the screening protocol for women at hereditary-familial risk of breast cancer: has the time come to rethink the role of BU according to different risk categories?

This article evaluates the breast cancer (BC) screening efficacy of biannual ultrasound (US) in three different risk categories. In a single-center, prospective, nonrandomized comparison study, BRCA mutation carriers and women with high risk (HR) or intermediate risk (IR) received mammography (MMG), ultrasound, (US) and Magnetic Resonance Imaging (MRI), scheduled according to the risk categories. Single and combined sensitivity were evaluated in specific groups of risk and the US performance at six-monthly interval was notably considered. Among 2,313 asymptomatic women at different risk (136 mutation carriers, 1,749 at HR and 428 at IR) 211 developed a BC, of which 193 (91.5%) were screen detected BC (SDBC) and 18 (8.5%) were interval BC (IBC). The SDBC detection rate (DR) was 11.2 per 1.000 person-years (37.9, 8.5 and 16.1 for BRCA, HR and IR, respectively); 116 BC were detected by MMG (DR = 6.6 × 1,000 persons-years), 62 by US (DR = 3.6 × 1,000 persons-years) and 15 by MRI, that was applied only in 60 BRCA women (DR = 37 × 1,000 persons-years). At the six-monthly US, 52 BC were detected (DR = 3.0 × 1,000 persons/years), of which 8 were BRCA-related. The most sensitive technique was MRI (93.7%) followed by MMG (55%) and US (29.4%). Combined sensitivity for MMG plus US was 100% in HR and 80.4% for IR women (p < 0.01). In BRCA mutated patients, MRI alone with annual US performed after six months, could be offered. In HR patients, MMG plus biannual US provide the most sensitive diagnosis and for IR group an annual MMG could be sufficient.

Toward 7T breast MRI clinical study: safety assessment using simulation of heterogeneous breast models in RF exposure

PURPOSE

To facilitate assessment of RF power deposition and temperature rise within the breast, we present a method to seamlessly join heterogeneous breast models with standard whole-body models and demonstrate simulations at 7 T.

METHODS

Finite-difference time-domain electromagnetic and bioheat simulations are performed to analyze the specific absorption rate (SAR) and temperature rise distributions in 36 Breast Imaging Reporting and Data System (BI-RADS) categorized breast models fused to 2 female whole-body models while transmitting from a 7T breast volume coil. The breast models are uncompressed in the prone position and feature heterogeneous tissue contents; fusion with human models uses affine transformation and the level-set method.

RESULTS

The fusion method produces a continuous transient from the chest region to the posterior portion of breast models while preserving the original volume and shape of breast models. Simulation results of both Ella and Hanako models indicate that the maximum local SAR, partial body SAR, and local tissue temperature rise are positively correlated with both breast density and the highest BI-RADS density classification. Additionally, maximum local tissue temperature rise is positively correlated with maximum 10-g SAR values.

CONCLUSION

Fibroglandular tissue content plays an important role in the distribution of SAR and temperature rise within breast tissue. The combined body-breast models preserve the integrity of breast models while concurrently exhibiting the loading of whole-body human models. The procedures presented in this simulation study facilitate safety assessments for breast MRI across the population at both clinical and ultrahigh field strengths.

Trends in breast cancer mortality by stage at diagnosis among young women in the United States

BACKGROUND

Assessing trends in breast cancer survival among young women who are largely unaffected by breast cancer screening will provide important information regarding improvements in the effectiveness of cancer care for breast cancer in the last few decades.

METHODS

The cohort for this study consisted of women who were diagnosed with breast cancer between ages 20 and 39 years from the Surveillance, Epidemiology, and End Results program's 9-registry areas from 1975 to 2015. Trends in the breast cancer incidence rate and survival were assessed among young women.

RESULTS

Among women aged 20 to 39 years, breast cancer incidence increased from 24.6 per 100,000 in 1975 to 31.7 per 100,000 in 2015 (annual percent change, 0.5; 95% confidence interval [CI], 0.4-0.6). Among women with breast cancer, 5-year breast-cancer-specific survival increased significantly from 74.0% during 1975 to 1979 to 88.5% during 2010 to 2015 (hazard ratio for dying from breast cancer for 2010-2015 vs 1975-1979, 0.37; 95% CI, 0.32-0.41). The increase in cancer-specific survival reached a plateau in 2005; however, among young women with metastatic breast cancer, it continued to increase after 2005, from 45.6% during 2005 to 2009 to 56.5% during 2010 to 2015 (hazard ratio for dying from breast cancer for 2010-2015 vs 2005-2009, 0.74; 95% CI, 0.60-0.92). Similar patterns also were observed for 5-year overall survival and among women aged 20 to 29 years and those aged 30 to 39 years.

CONCLUSIONS

There were substantial improvements in the effectiveness of breast cancer treatment on overall and cancer-specific survival from 1975 to 2015. However, improvements appeared to have reached a plateau after 2005, except among young women with metastatic breast cancer, in whom survival continued to improve throughout the period.

Breast Cancer Screening and Social Media: a Content Analysis of Evidence Use and Guideline Opinions on Twitter

There is ongoing debate regarding the best mammography screening practices. Twitter has become a powerful tool for disseminating medical news and fostering healthcare conversations; however, little work has been done examining these conversations in the context of how users are sharing evidence and discussing current guidelines for breast cancer screening. To characterize the Twitter conversation on mammography and assess the quality of evidence used as well as opinions regarding current screening guidelines, individual tweets using mammography-related hashtags were prospectively pulled from Twitter from 5 November 2015 to 11 December 2015. Content analysis was performed on the tweets by abstracting data related to user demographics, content, evidence use, and guideline opinions. Standard descriptive statistics were used to summarize the results. Comparisons were made by demographics, tweet type (testable claim, advice, personal experience, etc.), and user type (non-healthcare, physician, cancer specialist, etc.). The primary outcomes were how users are tweeting about breast cancer screening, the quality of evidence they are using, and their opinions regarding guidelines. The most frequent user type of the 1345 tweets was "non-healthcare" with 323 tweets (32.5%). Physicians had 1.87 times higher odds (95% CI, 0.69-5.07) of providing explicit support with a reference and 11.70 times higher odds (95% CI, 3.41-40.13) of posting a tweet likely to be supported by the scientific community compared to non-healthcare users. Only 2.9% of guideline tweets approved of the guidelines while 14.6% claimed to be confused by them. Non-healthcare users comprise a significant proportion of participants in mammography conversations, with tweets often containing claims that are false, not explicitly backed by scientific evidence, and in favor of alternative "natural" breast cancer prevention and treatment. Furthermore, users appear to have low approval and confusion regarding screening guidelines. These findings suggest that more efforts are needed to educate and disseminate accurate information to the general public regarding breast cancer prevention modalities, emphasizing the safety of mammography and the harms of replacing conventional prevention and treatment modalities with unsubstantiated alternatives.

Characterizing and eliminating errors in enhancement and subtraction artifacts in dynamic contrast-enhanced breast MRI: Chemical shift artifact of the third kind

PURPOSE

To characterize errors in enhancement in breast dynamic contrast-enhanced (DCE) MRI studies as a function of echo time and determine the source of dark band artifacts in clinical subtraction images.

METHODS

Computer simulations, oil and water substitute (methylene chloride), as well as an American College of Radiology quality control phantom were tested. Routine clinical DCE breast MRI study was bracketed with (accelerated) in-phase DCE acquisitions in five patients.

RESULTS

Simulation results demonstrated up to -160% suppression of the expected enhancement caused by differential enhancement of fat and water. Two-dimensional gradient-recalled echo and fat-suppressed 3D GRE phantom imaging confirmed the simulation results and showed that fat suppression does not eliminate the artifact. In vivo in-phase DCE images showed increased enhancement consistent with predictions and also confirmed increased spatial blurring on in-phase 3D gradient-recalled echo images. Combined multi-dimensional partial Fourier and parallel imaging provided a time-equivalent in-phase DCE MRI acquisition.

CONCLUSION

Errors in expected enhancement occur in DCE breast MRI subtraction images because of differential enhancement of fat and water and incomplete fat signal suppression. These errors can lead to artificial suppression of enhancement as well as dark band artifacts on subtraction images. These artifacts can be eliminated with a time-equivalent in-phase fat-suppressed 3D gradient-recalled echo sequence. Understanding chemical shift artifact of the third kind, a unique artifact of artificial enhancement suppression in the presence of intravoxel fat and water signal, will aid DCE breast MRI image interpretation. In-phase acquisitions (combined with simultaneous minimum echo time or opposed-phase echoes) may facilitate qualitative, quantitative and longitudinal analysis of contrast enhancement. Magn Reson Med 79:2277-2289, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Patient Perceptions of Breast Cancer Risk in Imaging-Detected Low-Risk Scenarios and Thresholds for Desired Intervention: A Multi-Institution Survey

PURPOSE

To determine women's perceptions of breast cancer risk and thresholds for desiring biopsy when considering BI-RADS 3 and 4A scenarios and recommendations, respectively.

MATERIALS AND METHODS

Women presenting for screening mammography from five geographically diverse medical centers were surveyed. Demographic information and baseline anxiety were queried. Participants were presented with scenarios of short-term imaging follow-up recommendations (ie, BI-RADS 3) and biopsy recommendations (ie, BI-RADS 4A) for low-risk mammographic abnormalities and asked to estimate their breast cancer risk for each scenario. Participants reported the threshold (ie, likelihood of cancer) where they would feel comfortable undergoing short-term imaging follow-up and biopsy and their anticipated regret for choosing short-term follow-up versus biopsy.

RESULTS

Analysis of 2,747 surveys showed that participants estimated breast cancer risk of 32.8% for a BI-RADS 3 and 41.1% for a BI-RADS 4A scenarios are significantly greater rates than clinically established rates (<2% [P < .001] and 2%-10% [P < .001], respectively). Over one-half (55.4%) of participants reported they would never want imaging follow-up if there was any chance of cancer; two-thirds (66.2%) reported they would desire biopsy if there was any chance of cancer. Participants reported greater anticipated regret (P < .001) and less relief and confidence (P < .001) with the decision to undergo follow-up imaging versus biopsy.

CONCLUSION

Women overestimate breast cancer risk associated with both BI-RADS 3 and 4A scenarios and desire very low biopsy thresholds. Greater anticipated regret and less relief and confidence was reported with the choice to undergo short-term imaging follow-up compared with biopsy.

Comparative study of ultrasonic elastography and conventional ultrasound in diagnosis of malignant anus neoplasm

The application value of conventional ultrasound and ultrasonic elastography (UE) in preoperative diagnosis and combined diagnosis of malignant anus neoplasms was investigated. One hundred and twenty patients, whose mass was detected by digital rectal examination, were examined using UE and conventional ultrasound before operation, and the results were compared with those of histopathological examinations after operation, so that the accuracy and imaging features of UE as well as UE combined with conventional ultrasound in diagnosing malignant anus neoplasm were analyzed. Among the 120 patients, 77 were diagnosed with benign lesions and 43 were diagnosed with malignant lesions via pathological diagnosis for anal canal lesion surgery. Conventional ultrasound before operation showed that 53 patients were diagnosed with benign lesions and 26 with malignant lesions. Compared with that in the pathological diagnosis results, the diagnostic accordance rate in preoperative conventional ultrasound was 65.8%. Through UE diagnosis, 66 patients had benign lesions and 39 patients had malignant lesions. Compared with that in the pathological diagnosis results, the diagnostic accordance rate in preoperative UE was 87.5%. After the examination via UE combined with conventional ultrasound before operation, 71 patients were diagnosed with benign lesions and 40 patients were diagnosed with malignant lesions; compared with that in the pathological diagnosis results, the diagnostic accordance rate was 92.5%. In terms of mass qualitative diagnosis, the sensitivity and specificity of conventional ultrasound were 60.5 and 68.8%, respectively; those of UE were 90.7 and 85.7%, respectively, and those of UE combined with conventional ultrasound were 93.0 and 92.2%, respectively. According to the analysis results of receiver operating characteristic (ROC) curve, the area under curve (AUC) of malignant anus neoplasm diagnosed via UE was 0.732 [95% confidence interval (95% CI), 0.211-2.534], the AUC via conventional ultrasound was 0.695 (95% CI, 0.517-0.932), and that via UE combined with conventional ultrasound was 0.823 (95% CI, 0.146-4.643). In conclusion, examinations utilizing UE combined with conventional ultrasound can increase the preoperative diagnostic accordance rate in malignant anus neoplasm, which can be used as an effective method for preoperative diagnosis of malignant anus neoplasm.

What Do Patients Want to Know? Questions and Concerns Regarding Mammography Expressed Through Social Media

PURPOSE

The purpose of this project is to identify questions and concerns patients have regarding breast cancer screening mammography to establish priorities in patient education and health care communication.

METHODS

A content analysis of posted questions (June 2010 to February 2017) containing the keywords mammogram and mammography was conducted on the social media question and answer website Quora (Quora Inc, Mountainview, California). Question topic, responses, and number of views were recorded. Comparisons were made by respondent type (medical professional or nonmedical professional) for screening recommendations and accompanying evidence. Descriptive statistics were employed to summarize the results.

RESULTS

Overall, 197,620 views of mammography-related questions were identified, focused on 51 questions and 172 responses (51 of 172 [29.7%] by medical professionals [n = 25]; 121 of 172 [70.3%] by nonmedical professionals [n = 121]). Mammographic efficacy (16 of 51 [31.4%]) and screening guidelines (10 of 51 [19.6%]) were the most frequently queried topics. Overall, the majority of respondents were supportive of screening mammography. Most medical professionals recommended screening mammography starting at age 40, even after revisions in guidelines. Among nonmedical professionals, 4 of 22 (18.2%) were against screening mammography with less consensus regarding appropriate age of initial screen. Health society websites and journal articles were the most commonly referenced sources among medical and nonmedical professionals, respectively.

CONCLUSION

A considerable interest in screening mammography guidelines and mammographic efficacy exists among users who seek health information on a social media question and answer website. Awareness of such platforms allows a unique opportunity for targeted health education and dissemination of accurate information, which may be able to reach a potentially untapped or hard-to-reach patient population.

Breast and Ovarian Cancer Penetrance Estimates Derived From Germline Multiple-Gene Sequencing Results in Women

Purpose

Multiple-gene, next-generation sequencing panels are increasingly used to assess hereditary cancer risks of patients with diverse personal and family cancer histories. The magnitude of breast and ovarian cancer risk associated with many clinically tested genes, and independent of family cancer history, remains to be quantified.

Methods

We queried a commercial laboratory database of 95,561 women tested clinically for hereditary cancer risk with a 25-gene ( APC, ATM, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CHEK2, MLH2, MSH2, MSH6, MUTYH, NBN, P14ARF, P16, PALB2, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, and TP53) next-generation sequencing panel. Multivariable logistic regression models accounting for family history were used to examine the association between pathogenic mutations and breast or ovarian cancer. As a confirmatory approach, a matched case-control analysis was conducted, defining cases as patients with breast or ovarian cancer and controls as women without cancer.

Results

One or more pathogenic mutations were detected in 6,775 (7%) of 95,561 women. Eight genes ( ATM, BARD1, BRCA1, BRCA2, CHEK2, PALB2, PTEN, and TP53) were associated with breast cancer, with odds ratios (ORs) ranging from two-fold ( ATM: OR, 1.74; 95% CI, 1.46 to 2.07) to six-fold ( BRCA1: OR, 5.91; 95% CI, 5.25 to 6.67). Eleven genes ( ATM, BRCA1, BRCA2, BRIP1, MLH1, MSH2, MSH6, NBN, STK11, RAD51C, and RAD51D) were associated with ovarian cancer, with OR ranging from two-fold ( ATM: OR, 1.69; 95% CI, 1.19 to 2.40) to 40-fold ( STK11: OR, 41.9; 95% CI, 5.55 to 315). Multivariable models and matched case-control analyses yielded similar results.

Conclusion

Among nearly 100,000 clinically tested women, 7% carried a pathogenic mutation in one or more cancer-associated genes. Associated breast and ovarian cancer risks ranged from two- to 40-fold after controlling for family history. These results may inform cancer risk counseling.

The Changing Landscape of Genetic Testing for Inherited Breast Cancer Predisposition

OPINION STATEMENT

The advent of multiple-gene germline panel testing has led to significant advances in hereditary breast and ovarian cancer risk assessment. These include guideline-specific cancer risk management recommendations for patients and their families, such as screening with breast magnetic resonance imaging and risk-reducing surgeries, which have the potential to reduce substantially the morbidity and mortality associated with a hereditary cancer predisposition. However, controversy remains about the clinical validity and actionability of genetic testing in a broader patient population. We discuss events leading to the wider availability of commercialized multiple-gene germline panel testing, the recent data that support using this powerful tool to improve cancer risk assessment and reduction strategies, and remaining challenges to clinical optimization of this new genetic technology.

Screening Mammography and Digital Breast Tomosynthesis: Controversies

Breast cancer screening with mammography reduces breast cancer mortality; however, diverging recommendations regarding screening have caused controversy. The emerging technology of digital breast tomosynthesis (DBT) may soon become the mainstay of breast cancer screening. We present recommendations for breast cancer screening based on guidelines. A PubMed literature review was performed and the results from five large clinical studies comparing the efficacy of digital mammography alone versus digital mammography with DBT are examined. We emphasize the importance of annual screening to reduce breast cancer mortality. Our review of the literature demonstrates that DBT increases cancer detection rates and reduces callbacks. Additional research is needed to determine whether the increased cancer detection rates are associated with a decrease in mortality.

Can diffusion-weighted imaging add information in the evaluation of breast lesions considered suspicious on magnetic resonance imaging?

OBJECTIVE

To assess the role of diffusion-weighted imaging (DWI) in the evaluation of breast lesions classified as suspicious on magnetic resonance imaging (MRI), correlating the findings with the results of the histological analysis.

MATERIALS AND METHODS

This was a retrospective, descriptive study based on a review of the medical records of 215 patients who were submitted to MRI with DWI before undergoing biopsy at a cancer center. Apparent diffusion coefficient (ADC) values were calculated for each lesion, and the result of the histological analysis was considered the gold standard.

RESULTS

The mean age was 49 years. We identified 252 lesions, 161 (63.9%) of which were found to be malignant in the histological analysis. The mean ADC value was higher for the benign lesions than for the malignant lesions (1.50 × 10-3 mm2/s vs. 0.97 × 10-3 mm2/s), the difference being statistically significant (p < 0.001). The ADC cut-off point with the greatest sensitivity and specificity on the receiver operating characteristic curve was 1.03 × 10-3 mm2/s. When the DWI and conventional MRI findings were combined, the accuracy reached 95.9%, with a sensitivity of 95.7% and a specificity of 96.4%.

CONCLUSION

The use of DWI could facilitate the characterization of breast lesions, especially those classified as BI-RADS 4, increasing the specificity and diagnostic accuracy of MRI.

Evaluation of the Efficacy of Clinical Breast Examination Gloves in the Diagnosis of Breast Lumps

INTRODUCTION

Recent studies have questioned the efficacy of mammography in reducing breast cancer-related mortality. Additionally, the efficacies of commercially available gloves marketed as aiding the detection of breast lumps have not been independently verified.

AIM

To evaluate the efficacy of clinical breast examination gloves in the detection of breast lumps.

MATERIALS AND METHODS

During the period from October 2011 to June 2012, patients were submitted to clinical examination with and without gloves. This prospective study involved 202 patients who underwent conventional clinical breast examination (test 1) or clinical breast examination with Sensifemme^® gloves (test 2). All patients underwent subsequent bilateral ultrasonography (test 3) to confirm the findings of the physical examinations. The Chi-square test was used to compare values, while the kappa concordance index was used to determine the concordance between the diagnostic tests.

RESULTS

The mean age of the patients was 43 years; 298 breast lumps were detected. In the clinical examination group (test 1), sensitivity was 54%, specificity was 78%, and accuracy was 57%. These rates for clinical breast examinations with gloves (test 2) were 68%, 58%, and 66%, respectively. The glove increased the diagnosis of breast nodules by 14%; the rate of false-positives was also higher (42% for test 2 compared to 22% for test 1). The accuracy of the glove was found to be superior to clinical examination after 100 patients had been examined. The kappa indices for test 1 vs. test 3 and for test 2 vs. test 3 were 0.15 and 0.16, respectively.

CONCLUSION

Clinical examination using the glove was more effective than clinical examination with bare hands for the diagnosis of breast lumps, as it increased the sensitivity and accuracy of lump detection. However, this was at the expense of a higher false-positive rate, which can lead to further tests, unnecessary biopsies, and patient anxiety. The concordance of clinical examination results (whether performed with or without the glove) with those of ultrasonography is weak. Moreover, the glove has a steep learning curve that may discourage its use in certain circumstances.

Differences Among a Modern Cohort of BRCA Mutation Carriers Choosing Bilateral Prophylactic Mastectomies Compared to Breast Surveillance

BACKGROUND

Women with a BRCA mutation have significantly elevated breast cancer risk, which can be reduced by >90% with bilateral prophylactic mastectomy (BPM). We sought to compare a cohort of BRCA mutation carriers choosing BPM versus breast surveillance to better elucidate factors that may impact decision making.

METHODS

Women with a BRCA mutation were retrospectively identified from a prospectively maintained database. The surveillance cohort (n = 313) consisted of women seen in a high-risk clinic between 2014 and 2016, while the surgery cohort (n = 142) consisted of women who underwent BPM between 2010 and 2016. Clinical and familial factors were compared between the groups.

RESULTS

Women choosing BPM were more likely to have a BRCA1 than BRCA2 mutation compared with the surveillance group (57 vs. 45%, p = 0.02) and were less likely to have a personal history of ovarian cancer (10 vs. 20%, p = 0.01). Furthermore, women undergoing BPM were more likely to be married (78 vs. 62%, p = 0.01), to have more children (median 2 vs. 1, p < 0.001), and to have undergone a prophylactic oophorectomy (61 vs. 37%, p < 0.001). Women choosing BPM had more first-degree relatives (63 vs. 48%, p = 0.01) or a sister (23 vs. 14%, p = 0.02) with a history of breast cancer and were more likely to have a family member with ovarian cancer under the age of 40 years (9 vs. 4%, p = 0.03). There was no difference in the number of prior breast biopsies or history of atypia/lobular carcinoma in situ.

CONCLUSION

The decision to undergo BPM appears multifactorial, with gene mutation, family history, and relationships appearing to have the strongest influence on decision making.

Routine Pre-Treatment MRI for Breast Cancer in a Single-Payer Medical Center: Effects on Surgical Choices, Timing and Outcomes

Introduction: Pre-operative MRI is being used with increasing frequency to evaluate breast cancer patients, but the debate surrounding risks and benefits of this use continues. At our institution, we instituted a standardized protocol for pre-operative MRI. Here, we compare patients seen prior to routine use of MRI to those seen after and examine effects on surgical choices, timing and outcomes.

Methods: This is a retrospective review of a prospectively collected database of all new invasive breast cancers seen from January 2007 to December 2012. The control group (CG) did not receive MRI, while the MRI group (MRG) underwent MRI according to our pretreatment protocol. Groups were compared with regards to basic demographics, initial surgical choices, need for re-excision, and surgical timing. The electronic medical records of patients in the MRG who underwent mastectomy as their initial surgery were examined closely to determine the main factors leading to their choice of surgery. Finally, correlation between findings on MRI and final surgical pathology was analyzed.

Results: Of 282 patients included, 38 were in the CG and 244 in the MRG; the groups were well matched. The MRG had a significantly higher percentage of patients choosing initial mastectomy (MRG: 47.1% vs CG 21.1%, p=0.003). Patients seen in the first 2 years of the study were less likely to choose mastectomy than those enrolled in the latter years (29.2%vs 48.6%, p=0.004). The MRG had a lower chance of return to the operating room for re-excision (15.2% vs 28.9%, p=0.035). The average time from initial imaging to initial surgery was approximately the same between groups (MRG: 39.7 days vs CG 42.1 days, p=0.45) and the MRG actually had shorter time to definitive (margin-negative) surgical management (MRG: 43.5 days vs CG: 50.3 days, p=0.079). One hundred-fifteen patients in the MRG underwent mastectomy as initial surgery. Of these, 64 (55.7%) had no additional findings on MRI and chose mastectomy based on patient preference; 30 patients (26.1%) (29 unilateral, 1 bilateral) had mastectomy because of MRI findings. Of the 31 breasts removed (29 unilateral and 1 bilateral mastectomies) because of MRI findings, 26 (83.9%) had histologic findings that correlated with the MRI findings, while 5 (16.1%) did not.

Conclusion: Patients receiving routine pre-treatment MRI had an increased mastectomy rate, but had a lower re-excision rate. We found no delay to initial surgical therapy and, perhaps more importantly, a slight decrease in time to margin-negative surgical therapy in the MRI group. Women choosing mastectomy after MRI did so because of personal preference over half of the time, while MRI findings influenced this choice in 26% of these women. When MRI findings did lead to mastectomy, these findings were confirmed by pathology results in the vast majority of cases.

Risk-based Breast Cancer Screening: Implications of Breast Density

The approach to breast cancer screening has changed over time from a general approach to a more personalized, risk-based approach. Women with dense breasts, one of the most prevalent risk factors, are now being informed that they are at increased risk of developing breast cancer and should consider supplemental screening beyond mammography. This article reviews the current evidence regarding the impact of breast density relative to other known risk factors, the evidence regarding supplemental screening for women with dense breasts, supplemental screening options, and recommendations for physicians having shared decision-making discussions with women who have dense breasts.

Qualitative Versus Quantitative Mammographic Breast Density Assessment: Applications for the US and Abroad

Mammographic breast density (MBD) has been proven to be an important risk factor for breast cancer and an important determinant of mammographic screening performance. The measurement of density has changed dramatically since its inception. Initial qualitative measurement methods have been found to have limited consistency between readers, and in regards to breast cancer risk. Following the introduction of full-field digital mammography, more sophisticated measurement methodology is now possible. Automated computer-based density measurements can provide consistent, reproducible, and objective results. In this review paper, we describe various methods currently available to assess MBD, and provide a discussion on the clinical utility of such methods for breast cancer screening.