Cost-effectiveness of alternative strategies for integrating MRI into breast cancer screening for women at high risk

Optimized, Person-Centered Workflow Design for a High-Throughput Breast MRI Screening Facility-A Simulation Study

OBJECTIVES

This project aims to model an optimal scanning environment for breast magnetic resonance imaging (MRI) screening based on real-life data to identify to what extent the logistics of breast MRI can be optimized.

MATERIALS AND METHODS

A novel concept for a breast MRI screening facility was developed considering layout of the building, workflow steps, used resources, and MRI protocols. The envisioned screening facility is person centered and aims for an efficient workflow-oriented design. Real-life data, collected from existing breast MRI screening workflows, during 62 scans in 3 different hospitals, were imported into a 3D simulation software for designing and testing new concepts. The model provided several realistic, virtual, logistical pathways for MRI screening and their outcome measures: throughput, waiting times, and other relevant variables.

RESULTS

The total average appointment time in the baseline scenario was 25:54 minutes, with 19:06 minutes of MRI room occupation. Simulated improvements consisted of optimizing processes and resources, facility layout, and scanning protocol. In the simulation, time spent in the MRI room was reduced by introducing an optimized facility layout, dockable tables, and adoption of an abbreviated MRI scanning protocol. The total average appointment time was reduced to 19:36 minutes, and in this scenario, the MRI room was occupied for 06:21 minutes. In the most promising scenario, screening of about 68 people per day (10 hours) on a single MRI scanner could be feasible, compared with 36 people per day in the baseline scenario.

CONCLUSIONS

This study suggests that by optimizing workflow MRI for breast screening total appointment duration and MRI occupation can be reduced. A throughput of up to 6 people per hour may be achieved, compared with 3 people per hour in the current setup.

Economic evaluation of breast MRI in screening - a systematic review and basic approach to cost-effectiveness analyses

Background

Economic evaluations have become an accepted methodology for decision makers to allocate resources in healthcare systems. Particularly in screening, where short-term costs are associated with long-term benefits, and adverse effects of screening intermingle, cost-effectiveness analyses provide a means to estimate the economic value of screening.

Purpose

To introduce the methodology of economic evaluations and to review the existing evidence on cost-effectiveness of MR-based breast cancer screening.

Materials and methods

The various concepts and techniques of economic evaluations critical to the interpretation of cost-effectiveness analyses are briefly introduced. In a systematic review of the literature, economic evaluations from the years 2000-2022 are reviewed.

Results

Despite a considerable heterogeneity in the reported input variables, outcome categories and methodological approaches, cost-effectiveness analyses report favorably on the economic value of breast MRI screening for different risk groups, including both short- and long-term costs and outcomes.

Conclusion

Economic evaluations indicate a strongly favorable economic value of breast MRI screening for women at high risk and for women with dense breast tissue.

Health Benefits and Cost-Effectiveness of Children's Oncology Group Breast Cancer Screening Guidelines for Chest-Irradiated Hodgkin Lymphoma Survivors

PURPOSE

To evaluate the outcomes and cost-effectiveness of the Children's Oncology Group Guideline recommendation for breast cancer (BC) screening using mammography (MAM) and breast magnetic resonance imaging (MRI) in female chest-irradiated childhood Hodgkin lymphoma (HL) survivors. Digital breast tomosynthesis (DBT), increasingly replacing MAM in practice, was also examined.

METHODS

Life years (LYs), quality-adjusted LYs (QALYs), BC mortality, health care costs, and false-positive screen frequencies of undergoing annual MAM, DBT, MRI, MAM + MRI, and DBT + MRI from age 25 to 74 years were estimated by microsimulation. BC risks and non-BC mortality were estimated from female 5-year survivors of HL in the Childhood Cancer Survivor Study and the US population. Test performance of MAM and MRI was synthesized from HL studies, and that of DBT from the general population. Costs (2017 US dollars [USD]) and utility weights were obtained from the medical literature. Incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

With 100% screening adherence, annual BC screening extended LYs by 0.34-0.46 years over no screening. If the willingness-to-pay threshold to gain a quality-adjusted LY was ICER < $100,000 USD, annual MAM at age 25-74 years was the only cost-effective strategy. When nonadherence was taken into consideration, only annual MAM at age 30-74 years (ICER = $56,972 USD) was cost-effective. Supplementing annual MAM with MRI costing $545 USD was not cost-effective under either adherence condition. If MRI costs were reduced to $300 USD, adding MRI to annual MAM at age 30-74 years could become more cost-effective, particularly in the reduced adherence condition (ICER = $133,682 USD).

CONCLUSION

Annual BC screening using MAM at age 30-74 years is effective and cost-effective in female chest-irradiated HL survivors. Although annual adjunct MRI is not cost-effective at $545 USD cost, it could become cost-effective as MRI cost is reduced, a plausible scenario with the emergent use of abbreviated MRI.

Cost-Effectiveness Analysis of Imaging Modalities for Breast Cancer Surveillance Among BRCA1/2 Mutation Carriers: A Systematic Review

Background

BRCA1/2 mutation carriers are suggested with regular breast cancer surveillance screening strategies using mammography with supplementary MRI as an adjunct tool in Western countries. From a cost-effectiveness perspective, however, the benefits of screening modalities remain controversial among different mutated genes and screening schedules.

Methods

We searched the MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases to collect and compare the results of different cost-effectiveness analyses. A simulated model was used to predict the impact of screening strategies in the target group on cost, life-year gained, quality-adjusted life years, and incremental cost-effectiveness ratio (ICER).

Results

Nine cost-effectiveness studies were included. Combined mammography and MRI strategy is cost-effective in BRCA1 mutation carriers for the middle-aged group (age 35 to 54). BRCA2 mutation carriers are less likely to benefit from adjunct MRI screening, which implies that mammography alone would be sufficient from a cost-effectiveness perspective, regardless of dense breast cancer.

Conclusions

Precision screening strategies among BRCA1/2 mutation carriers should be conducted according to the acceptable ICER, i.e., a combination of mammography and MRI for BRCA1 mutation carriers and mammography alone for BRCA2 mutation carriers.

Systematic Review Registration

PROSPERO, identifier CRD42020205471.

Economic potential of abbreviated breast MRI for screening women with dense breast tissue for breast cancer

OBJECTIVES

Abbreviated breast MRI (AB-MRI) was introduced to reduce both examination and image reading times and to improve cost-effectiveness of breast cancer screening. The aim of this model-based economic study was to analyze the cost-effectiveness of full protocol breast MRI (FB-MRI) vs. AB-MRI in screening women with dense breast tissue for breast cancer.

METHODS

Decision analysis and a Markov model were designed to model the cumulative costs and effects of biennial screening in terms of quality-adjusted life years (QALYs) from a US healthcare system perspective. Model input parameters for a cohort of women with dense breast tissue were adopted from recent literature. The impact of varying AB-MRI costs per examination as well as specificity on the resulting cost-effectiveness was modeled within deterministic sensitivity analyses.

RESULTS

At an assumed cost per examination of $ 263 for AB-MRI (84% of the cost of a FB-MRI examination), the discounted cumulative costs of both MR-based strategies accounted comparably. Reducing the costs of AB-MRI below $ 259 (82% of the cost of a FB-MRI examination, respectively), the incremental cost-effectiveness ratio of FB-MRI exceeded the willingness to pay threshold and the AB-MRI-strategy should be considered preferable in terms of cost-effectiveness.

CONCLUSIONS

Our preliminary findings indicate that AB-MRI may be considered cost-effective compared to FB-MRI for screening women with dense breast tissue for breast cancer, as long as the costs per examination do not exceed 82% of the cost of a FB-MRI examination.

KEY POINTS

• Cost-effectiveness of abbreviated breast MRI is affected by reductions in specificity and resulting false positive findings and increased recall rates. • Abbreviated breast MRI may be cost-effective up to a cost per examination of 82% of the cost of a full protocol examination. • Abbreviated breast MRI could be an economically preferable alternative to full protocol breast MRI in screening women with dense breast tissue.

Cost-Effectiveness of MR-Mammography in Breast Cancer Screening of Women With Extremely Dense Breasts After Two Rounds of Screening

Objectives

To evaluate the cost-effectiveness of MR-mammography (MRM) vs. x-ray based mammography (XM) in two-yearly screening women of intermediate risk for breast cancer in the light of recent literature.

Methods

Decision analysis and Markov modelling were used to compare cumulative costs (in US-$) and outcomes (in QALYs) of MRM vs. XM over the model runtime of 20 years. The perspective of the U.S. healthcare system was selected. Incremental cost-effectiveness ratios (ICER) were calculated and related to a willingness to pay-threshold of $ 100,000 per QALY in order to evaluate the cost-effectiveness. Deterministic and probabilistic sensitivity analyses were conducted to test the impact of variations of the input parameters. In particular, variations of the rate of false positive findings beyond the first screening round and their impact on cost-effectiveness were assessed.

Results

Breast cancer screening with MRM resulted in increased costs and superior effectiveness. Cumulative average costs of $ 6,081 per woman and cumulative effects of 15.12 QALYs were determined for MRM, whereas screening with XM resulted in costs of $ 5,810 and 15.10 QALYs, resulting in an ICER of $ 13,493 per QALY gained. When the specificity of MRM in the second and subsequent screening rounds was varied from 92% to 99%, the ICER resulted in a range from $ 38,849 to $ 5,062 per QALY.

Conclusions

Based on most recent data on the diagnostic performance beyond the first screening round, MRM may remain the economically preferable alternative in screening women of intermediate risk for breast cancer due to their dense breast tissue.

Cost-Sharing and Out-of-Pocket Cost for Women Who Received MRI for Breast Cancer Screening

BACKGROUND

The financial protection of the Affordable Care Act's (ACA) prevention provision doesn't apply to breast MRI but only to mammography for breast cancer screening. The purpose of the study is to examine the financial burden among women who received breast MRI for screening.

METHODS

This observational study used the Marketscan® database. Women underwent breast MRI between 2009 and 2017 and had screening mammography within 6 months of the MRI were included. We compared the time trend of the proportion of zero cost-share for women undergoing screening mammography and that for MRI. We quantified out-of-pocket (OOP) costs as the sum of copayment, coinsurance, and deductible and defined zero cost-share as having no OOP cost. We conducted multivariable logistic regression and two-part model to examine factors associated with zero cost-share and OOP costs of MRI, respectively.

RESULTS

16,341 women had a screening breast MRI during the study period. The proportion of screening MRI claims with zero cost-share decreased from 43.1% (2009) to 26.2% (2017). The adjusted mean OOP cost for women in high-deductible plans was more than twice the cost for their counterparts ($549 vs. $251, 2-sided P < .001). Women who resided in the South in the post-ACA era were less likely to have zero cost-share and paid higher OOP costs for screening MRI.

CONCLUSIONS

Many women are subject to high financial burden when receiving MRI for breast cancer screening. Those enrolled in high-deductible plans and who reside in the South are especially vulnerable financially.

Cost-effectiveness analysis in radiology: methods, results and implications

BACKGROUND

 Diagnostic radiological examinations as well as interventional radiological therapies are performed at a steadily increasing rate amidst increasingly limited resources in healthcare systems. Given their potential to contribute decisively to optimized therapy, in most cases associated short-term direct costs can be well justified from a clinical perspective. However, to realize their clinical benefits, they must also succeed in justifying them to payers and policymakers. Therefore, the aim of this work is to present suitable methods for economic analysis of radiological precedures and to elaborate their relevance for radiology.

METHODOLOGY

 Methods and metrics of cost-effectiveness analysis are presented and then exemplified using the example cases of MR mammography and interventional treatment of oligometastatic tumor disease of the liver.

RESULTS

 Cost-effectiveness considerations, taking into account long-term gains in lifespan and quality of life, as well as potential savings through improved treatment planning, do often objectively and credibly justify short-term additional costs.

CONCLUSIONS

 Cost-effectiveness analyses performed with radiological and health economic expertise can support the establishment of new radiological technologies in diagnostics and therapy.

KEY POINTS

  · When radiological procedures are employed, short-term costs are often offset by significant long-term benefits.. · Radiological examinations and therapies must be justified in the context of limited economic resources.. · Economic methodologies can be used to quantify the quality and cost-effectiveness of radiological methods.. · Such analyses as well as targeted training should be encouraged to provide greater transparency..

CITATION FORMAT

· Froelich MF, Kunz WG, Tollens F et al. Cost-effectiveness analysis in radiology: methods, results and implications. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1502-7830.

Incorporating Baseline Breast Density When Screening Women at Average Risk for Breast Cancer : A Cost-Effectiveness Analysis

BACKGROUND

Breast density classification is largely determined by mammography, making the timing of the first screening mammogram clinically important.

OBJECTIVE

To evaluate the cost-effectiveness of breast cancer screening strategies that are stratified by breast density.

DESIGN

Microsimulation model to generate the natural history of breast cancer for women with and those without dense breasts and assessment of the cost-effectiveness of strategies tailored to breast density and nontailored strategies.

DATA SOURCES

Model parameters from the literature; statistical modeling; and analysis of Surveillance, Epidemiology, and End Results-Medicare data.

TARGET POPULATION

Women aged 40 years or older.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

No screening; biennial or triennial mammography from age 50 to 75 years; annual mammography from age 50 to 75 years for women with dense breasts at age 50 years and biennial or triennial mammography from age 50 to 75 years for those without dense breasts at age 50 years; and annual mammography at age 40 to 75 years for women with dense breasts at age 40 years and biennial or triennial mammography at age 50 to 75 years for those without dense breasts at age 40 years.

OUTCOME MEASURES

Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.

RESULTS OF BASE-CASE ANALYSIS

Baseline screening at age 40 years followed by annual screening at age 40 to 75 years for women with dense breasts and biennial screening at age 50 to 75 years for women without dense breasts was effective and cost-effective, yielding an incremental cost-effectiveness ratio of $36 200 per QALY versus the biennial strategy at age 50 to 75 years.

RESULTS OF SENSITIVITY ANALYSIS

At a societal willingness-to-pay threshold of $100 000 per QALY, the probability that the density-stratified strategy at age 40 years was optimal was 56% compared with 6 other strategies.

LIMITATION

Findings may not be generalizable outside the United States.

CONCLUSION

The study findings advocate for breast density-stratified screening with baseline mammography at age 40 years.

PRIMARY FUNDING SOURCE

National Cancer Institute.

SPAER: Sparse Deep Convolutional Autoencoder Model to Extract Low Dimensional Imaging Biomarkers for Early Detection of Breast Cancer Using Dynamic Thermography

Early diagnosis of breast cancer unequivocally improves the survival rate of patients and is crucial for disease treatment. With the current developments in infrared imaging, breast screening using dynamic thermography seems to be a great complementary method for clinical breast examination (CBE) prior to mammography. In this study, we propose a sparse deep convolutional autoencoder model named SPAER to extract low-dimensional deep thermomics to aid breast cancer diagnosis. The model receives multichannel, low-rank, approximated thermal bases as input images. SPAER provides a solution for high-dimensional deep learning features and selects the predominant basis matrix using matrix factorization techniques. The model has been evaluated using five state-of-the-art matrix factorization methods and 208 thermal breast cancer screening cases. The best accuracy was for non-negative matrix factorization (NMF)-SPAER + Clinical and NMF-SPAER for maintaining thermal heterogeneity, leading to finding symptomatic cases with accuracies of 78.2% (74.3–82.5%) and 77.7% (70.9–82.1%), respectively. SPAER showed significant robustness when tested for additive Gaussian noise cases (3–20% noise), evaluated by the signal-to-noise ratio (SNR). The results suggest high performance of SPAER for preserveing thermal heterogeneity, and it can be used as a noninvasive in vivo tool aiding CBE in the early detection of breast cancer.

Cost-Effectiveness of Digital Breast Tomosynthesis vs. Abbreviated Breast MRI for Screening Women with Intermediate Risk of Breast Cancer-How Low-Cost Must MRI Be?

BACKGROUND

Digital breast tomosynthesis (DBT) and abbreviated breast MRI (AB-MRI) offer superior diagnostic performance compared to conventional mammography in screening women with intermediate risk of breast cancer due to dense breast tissue. The aim of this model-based economic evaluation was to analyze whether AB-MRI is cost-effective in this cohort compared to DBT.

METHODS

Decision analysis and Markov simulations were used to model the cumulative costs and quality-adjusted life-years (QALYs) over a time horizon of 30 years. Model input parameters were adopted from recent literature. Deterministic and probabilistic sensitivity analyses were applied to test the stability of the model.

RESULTS

In the base-case scenario, the costs of an AB-MRI examination were defined to equal the costs of a full protocol acquisition. Two-yearly screening of women with dense breasts resulted in cumulative discounted costs of $8798 and $9505 for DBT and AB-MRI, and cumulative discounted effects of 19.23 and 19.27 QALYs, respectively, with an incremental cost-effectiveness ratio of $20,807 per QALY gained in the base-case scenario. By reducing the cost of an AB-MRI examination below a threshold of $241 in sensitivity analyses, AB-MRI would become cost-saving compared to DBT.

CONCLUSION

In comparison to DBT, AB-MRI can be considered cost-effective up to a price per examination of $593 in screening patients at intermediate risk of breast cancer.

Impact of specificity on cost-effectiveness of screening women at high risk of breast cancer with magnetic resonance imaging, mammography and ultrasound

PURPOSE

Aim of this study was to analyze the comparative cost-effectiveness of MR-mammography vs conventional imaging in a screening setting for women with high risk of breast cancer, with particular focus on the impact of specificity of MRM.

METHOD

Decision analytic modelling and Markov Modelling were applied to evaluate cumulative costs of each screening modality and their subsequent treatments as well as cumulative outcomes in quality adjusted life years (QALYs). For the selected time horizon of 30 years, false positive and false negative results were included. Model input parameters for women with high risk of breast cancer were estimated based on published data from a US healthcare system perspective. Major influence factors were identified and evaluated in a deterministic sensitivity analysis. Based on current recommendations for economic evaluations, a probabilistic sensitivity analysis was conducted to test the model stability.

RESULTS

In a base-case analysis, screening with XM vs. MRM and treatment resulted in overall costs of $36,201.57 vs. $39,050.97 and a cumulative effectiveness of 19.53 QALYs vs. 19.59 QALYs. This led to an incremental cost-effectiveness ratio (ICER) of $ 45,373.94 per QALY for MRM. US and XM + US resulted in ICER values higher than the willingness to pay (WTP). In the sensitivity analyses, MRM remained a cost-effective strategy for screening high-risk patients as long as the specificity of MRM did not drop below 86.7 %.

CONCLUSION

In high-risk breast cancer patients, MRM can be regarded as a cost-effective alternative to XM in a yearly screening setting. Specificity may be an important cost driver in settings with yearly screening intervals.

Detecting Vasodilation as Potential Diagnostic Biomarker in Breast Cancer Using Deep Learning-Driven Thermomics

Breast cancer is the most common cancer in women. Early diagnosis improves outcome and survival, which is the cornerstone of breast cancer treatment. Thermography has been utilized as a complementary diagnostic technique in breast cancer detection. Artificial intelligence (AI) has the capacity to capture and analyze the entire concealed information in thermography. In this study, we propose a method to potentially detect the immunohistochemical response to breast cancer by finding thermal heterogeneous patterns in the targeted area. In this study for breast cancer screening 208 subjects participated and normal and abnormal (diagnosed by mammography or clinical diagnosis) conditions were analyzed. High-dimensional deep thermomic features were extracted from the ResNet-50 pre-trained model from low-rank thermal matrix approximation using sparse principal component analysis. Then, a sparse deep autoencoder designed and trained for such data decreases the dimensionality to 16 latent space thermomic features. A random forest model was used to classify the participants. The proposed method preserves thermal heterogeneity, which leads to successful classification between normal and abnormal subjects with an accuracy of 78.16% (73.3-81.07%). By non-invasively capturing a thermal map of the entire tumor, the proposed method can assist in screening and diagnosing this malignancy. These thermal signatures may preoperatively stratify the patients for personalized treatment planning and potentially monitor the patients during treatment.

Cost-effectiveness of MR-mammography vs. conventional mammography in screening patients at intermediate risk of breast cancer - A model-based economic evaluation

PURPOSE

The aim of this study was to analyze the cost-effectiveness of screening patients of intermediate risk of breast cancer with MR-Mammography (MRM) versus conventional mammography (XM).

METHOD

A decision model for both diagnostic modalities and a subsequent markov model for the simulation of follow-up costs and outcomes was developed. Input parameters were acquired from published literature for this markov modelling study. The expected cumulative costs and outcomes were calculated for both modalities in a 30-year timeframe in US-dollar ($) and quality-adjusted life years (QALYs). A deterministic sensitivity analysis and a probabilistic sensitivity analysis incorporating 30,000 Monte Carlo iterations were performed to investigate the model stability.

RESULTS

In total, XM with its consecutive treatments resulted in total costs of $ 5,492.68 and an average cumulative quality of life of 18.87 QALYs, compared to MRM with costs of $ 5,878.66 and 18.92 QALYs. The corresponding incremental cost-effectiveness ratio (ICER) for MRM was $ 8,797.60 per QALY - distinctly below international willingness-to-pay thresholds for cost-effectiveness. The results were confirmed within the limits of the sensitivity analyses.

CONCLUSIONS

In patients with intermediate risk for breast cancer due to their dense breast tissue, two-yearly screening with MRM may be considered as cost-effective.

Cost-effectiveness of MR-mammography as a solitary imaging technique in women with dense breasts: an economic evaluation of the prospective TK-Study

Objectives

To evaluate the economic implications of our previous study on the use of MR-mammography (MRM) as a solitary imaging tool in women at intermediate risk due to dense breasts.

Background

In our previous study, we found MRM to be a specific diagnostic tool with high accuracy in patients with dense breasts representing a patient collective at intermediate risk of breast cancer. For this study, we examined whether MRM is an economical alternative.

Methods

For the determination of outcomes and costs, a decision model based on potential diagnostic results of MRM was developed. Quality of life was estimated in a Markov chain model distinguishing between the absence of malignancy, the presence of malignancy, and death. Input parameters were utilized from the prospective TK-Study. To investigate the economic impact of MRM, overall costs in € and outcomes of MRM in quality-adjusted life years (QALYs) were estimated. A deterministic sensitivity analysis was performed.

Results

MRM was associated with expected costs of 1650.48 € in the 5-year period and an expected cumulative outcome of 4.69 QALYs. A true positive diagnosis resulted in significantly lower costs and a higher quality of life when compared to the consequences of a false negative result. In the deterministic sensitivity analysis, treatment costs had more impact on overall costs than the costs of MRM. The total costs per patient remained below 2500 € in the 5-year period.

Conclusion

MRM, as a solitary imaging tool in patients at intermediate risk due to dense breasts, is economically feasible.

Key Points

• In patients with dense breasts (i.e., patients at intermediate risk of breast cancer), the relative cost of MR-mammography examinations only had moderate impact on overall costs.

• This is due to cost-savings through the application of a sensitive imaging technique resulting in an optimized staging and therapy planning.

• MR-mammography, unaccompanied by mammography or ultrasound in patients with dense breasts, was economically feasible in our analysis.

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.

Screening in patients with increased risk of breast cancer (part 1): pros and cons of MRI screening

Screening plays an important role in women with a high risk of breast cancer. Given this population's high incidence of breast cancer and younger age of onset compared to the general population, it is recommended that screening starts earlier. There is ample evidence that magnetic resonance imaging (MRI) is the most sensitive diagnostic tool, and American and the European guidelines both recommend annual MRI screening (with supplementary annual mammography) as the optimum screening modality. Nevertheless, the current guidelines do not totally agree about the recommendations for MRI screening in some subgroups of patients. The first part of this article on screening in women with increased risk of breast cancer reviews the literature to explain and evaluate the advantages of MRI screening compared to screening with mammography alone: increased detection of smaller cancers with less associated lymph node involvement and a reduction in the rate of interval cancers, which can have an impact on survival and mortality (with comparable effects to other preventative measures). At the same time, however, we would like to reflect on the drawbacks of MRI screening that affect its applicability.

Personalized breast cancer screening strategies: A systematic review and quality assessment

BACKGROUND

The effectiveness of breast cancer screening is still under debate. Our objective was to systematically review studies assessing personalized breast cancer screening strategies based on women's individual risk and to conduct a risk of bias assessment.

METHODS

We followed the standard methods of The Cochrane Collaboration and PRISMA declaration and searched the MEDLINE, EMBASE and Clinical Trials databases for studies published in English. The quality of the studies was assessed using the ISPOR-AMCP-NPC Questionnaire and The Cochrane Risk of Bias Tool. Two independent reviewers screened full texts and evaluated the risk of bias.

RESULTS

Out of the 1533 initially retrieved citations, we included 13 studies. Three studies were randomized controlled trials, while nine were mathematical modeling studies, and one was an observational pilot study. The trials are in the recruitment phase and have not yet reported their results. All three trials used breast density and age to define risk groups, and two of them included family history, previous biopsies, and genetic information. Among the mathematical modeling studies, the main risk factors used to define risk groups were breast density, age, family history, and previous biopsies. Six studies used genetic information to define risk groups. The most common outcome measures were the gain in quality-adjusted life years (QALY), absolute costs, and incremental cost-effectiveness ratio (ICER), while the main outcome in the observational study was the detection rate. In all models, personalized screening strategies were shown to be effective. The randomized trials were of good quality. The modeling studies showed moderate risk of bias but there was wide variability across studies. The observational study showed a low risk of bias but its utility was moderate due to its pilot design and its relatively small scale.

CONCLUSIONS

There is some evidence of the effectiveness of screening personalization in terms of QUALYs and ICER from the modeling studies and the observational study. However, evidence is lacking on feasibility and acceptance by the target population.

REVIEW REGISTRATION

PROSPERO: CRD42018110483.

Association of Retrospective Peer Review and Positive Predictive Value of Magnetic Resonance Imaging-Guided Vacuum-Assisted Needle Biopsies of Breast

Objective

To evaluate the association between retrospective peer review of breast magnetic resonance imaging-guided vacuum-assisted needle biopsies and positive predictive value of subsequent magnetic resonance imaging-guided biopsies.

Materials and Methods

In January, 2015, a weekly conference was initiated in our institution to evaluate all breast magnetic resonance imaging-guided vacuum-assisted needle biopsies performed over January 1, 2014-December 31, 2015. During this weekly conferences, breast dynamic contrast-enhanced magnetic resonance imaging findings of 6 anonymized cases were discussed and then the faculty voted on whether they agree with the biopsy indication, accurate sampling and radiology-pathology correlation. We retrospectively reviewed and compared the magnetic resonance imaging indication, benign or malignant pathology rates, lesion types and the positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsy in the years before and after initiating this group peer review.

Results

The number of dynamic contrast-enhanced magnetic resonance imaging and magnetic resonance imaging-guided vacuum-assisted needle biopsies before and after initiating the review were 1447 vs 1596 (p=0.0002), and 253 (17.5%) vs 203 (12.7%) (p=0.04), respectively. There was a significant decrease in the number of benign biopsies in 2015 (n=104) compared to 2014 (n=154, p=0.04). The positive predictive value of magnetic resonance imaging-guided biopsy significantly increased after group review was implemented (Positive predictive value in 2014=%39.1 and positive predictive value in 2015=%48.8) (p=0.03), although the indications (p=0.49), history of breast cancer (p=0.14), biopsied magnetic resonance imaging lesion types (p=0.53) were not different. Less surgical excision was performed on magnetic resonance imaging-guided vacuum-assisted needle biopsy identified high-risk lesions in 2015 (p=0.25).

Conclusion

Our study showed an association between retrospective peer review of past biopsies and increased positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsies in our institution.

Multireader Study on the Diagnostic Accuracy of Ultrafast Breast Magnetic Resonance Imaging for Breast Cancer Screening

OBJECTIVES

Breast cancer screening using magnetic resonance imaging (MRI) has limited accessibility due to high costs of breast MRI. Ultrafast dynamic contrast-enhanced breast MRI can be acquired within 2 minutes. We aimed to assess whether screening performance of breast radiologist using an ultrafast breast MRI-only screening protocol is as good as performance using a full multiparametric diagnostic MRI protocol (FDP).

MATERIALS AND METHODS

The institutional review board approved this study, and waived the need for informed consent. Between January 2012 and June 2014, 1791 consecutive breast cancer screening examinations from 954 women with a lifetime risk of more than 20% were prospectively collected. All women were scanned using a 3 T protocol interleaving ultrafast breast MRI acquisitions in a full multiparametric diagnostic MRI protocol consisting of standard dynamic contrast-enhanced sequences, diffusion-weighted imaging, and T2-weighted imaging. Subsequently, a case set was created including all biopsied screen-detected lesions in this period (31 malignant and 54 benign) and 116 randomly selected normal cases with more than 2 years of follow-up. Prior examinations were included when available. Seven dedicated breast radiologists read all 201 examinations and 153 available priors once using the FDP and once using ultrafast breast MRI only in 2 counterbalanced and crossed-over reading sessions.

RESULTS

For reading the FDP versus ultrafast breast MRI alone, sensitivity was 0.86 (95% confidence interval [CI], 0.81-0.90) versus 0.84 (95% CI, 0.78-0.88) (P = 0.50), specificity was 0.76 (95% CI, 0.74-0.79) versus 0.82 (95% CI, 0.79-0.84) (P = 0.002), positive predictive value was 0.40 (95% CI, 0.36-0.45) versus 0.45 (95% CI, 0.41-0.50) (P = 0.14), and area under the receiver operating characteristics curve was 0.89 (95% CI, 0.82-0.96) versus 0.89 (95% CI, 0.82-0.96) (P = 0.83). Ultrafast breast MRI reading was 22.8% faster than reading FDP (P < 0.001). Interreader agreement is significantly better for ultrafast breast MRI (κ = 0.730; 95% CI, 0.699-0.761) than for the FDP (κ = 0.665; 95% CI, 0.633-0.696).

CONCLUSIONS

Breast MRI screening using only an ultrafast breast MRI protocol is noninferior to screening with an FDP and may result in significantly higher screening specificity and shorter reading time.

Comparison of Contrast-Enhanced Mammography With Conventional Digital Mammography in Breast Cancer Screening: A Pilot Study

PURPOSE

To perform a pilot evaluation of contrast-enhanced mammography (CEM) for screening to determine whether it can improve accuracy and reader confidence in diagnosis.

METHODS AND MATERIALS

This institutional review board-approved reader study was comprised of 64 de-identified CEM cases acquired from December 1, 2014, to June 7, 2016, including 48 negative, 5 biopsy-proven benign, and 11 biopsy-proven malignancies. Negative cases were followed for at least 2 years without evidence of cancer. Ten breast imagers of varying experience first rated the low-energy (LE) mammogram and then the CEM examination using BI-RADS categories and a 5-point Likert scale for confidence in diagnosis.

RESULTS

There were 635 out a total possible 640 complete reader interpretations included in this analysis. The remaining five incomplete interpretations were excluded. Median sensitivity and specificity improved with the addition of CEM (sensitivity: 0.86 [95% confidence interval {CI}: 0.74-0.95] versus 1 [95% CI: 0.83-1.00], specificity: 0.85 [95% CI: 0.64-0.94] versus 0.88 [95% CI: 0.80-0.92]). Individual receiver operating characteristic curves showed significant improvement with CEM (mean area under the curve increase = 0.056 [95% CI: 0.015-0.097], P = .002). The addition of CEM significantly improved average confidence in 5 of 10 readers when compared with LE (P < .0001) and improved pooled confidence across all tissue density categories, except the almost entirely fatty category. There was a trend toward improved confidence with increasing tissue density with CEM. Degree of background parenchymal enhancement did not affect readers' level of improvement in confidence when interpreting CEM.

SUMMARY

CEM improved reader performance and confidence compared with viewing only LE, suggesting a role for CEM in breast cancer screening for which larger trials are warranted.

Assessing the Cost-Effectiveness of Updated Breast Cancer Screening Guidelines for Average-Risk Women

BACKGROUND

Several specialty societies have recently updated their breast cancer screening guidelines in late 2015/early 2016.

OBJECTIVES

To evaluate the cost-effectiveness of US-based mammography screening guidelines.

METHODS

We developed a microsimulation model to generate the natural history of invasive breast cancer and capture how screening and treatment modified the natural course of the disease. We used the model to assess the cost-effectiveness of screening strategies, including annual screening starting at the age of 40 years, biennial screening starting at the age of 50 years, and a hybrid strategy that begins screening at the age of 45 years and transitions to biennial screening at the age of 55 years, combined with three cessation ages: 75 years, 80 years, and no upper age limit. Findings were summarized as incremental cost-effectiveness ratio (cost per quality-adjusted life-year [QALY]) and cost-effectiveness acceptability frontier.

RESULTS

The screening strategy that starts annual mammography at the age of 45 years and switches to biennial screening between the ages of 55 and 75 years was the most cost-effective, yielding an incremental cost-effectiveness ratio of $40,135/QALY. Probabilistic analysis showed that the hybrid strategy had the highest probability of being optimal when the societal willingness to pay was between $44,000/QALY and $103,500/QALY. Within the range of commonly accepted societal willingness to pay, no optimal strategy involved screening with a cessation age of 80 years or older.

CONCLUSIONS

The screening strategy built on a hybrid design is the most cost-effective for average-risk women. By considering the balance between benefits and harms in forming its recommendations, this hybrid screening strategy has the potential to optimize the health care system's investment in the early detection and treatment of breast cancer.

Simulation modeling for stratified breast cancer screening - a systematic review of cost and quality of life assumptions

BACKGROUND

The economic evaluation of stratified breast cancer screening gains momentum, but produces also very diverse results. Systematic reviews so far focused on modeling techniques and epidemiologic assumptions. However, cost and utility parameters received only little attention. This systematic review assesses simulation models for stratified breast cancer screening based on their cost and utility parameters in each phase of breast cancer screening and care.

METHODS

A literature review was conducted to compare economic evaluations with simulation models of personalized breast cancer screening. Study quality was assessed using reporting guidelines. Cost and utility inputs were extracted, standardized and structured using a care delivery framework. Studies were then clustered according to their study aim and parameters were compared within the clusters.

RESULTS

Eighteen studies were identified within three study clusters. Reporting quality was very diverse in all three clusters. Only two studies in cluster 1, four studies in cluster 2 and one study in cluster 3 scored high in the quality appraisal. In addition to the quality appraisal, this review assessed if the simulation models were consistent in integrating all relevant phases of care, if utility parameters were consistent and methodological sound and if cost were compatible and consistent in the actual parameters used for screening, diagnostic work up and treatment. Of 18 studies, only three studies did not show signs of potential bias.

CONCLUSION

This systematic review shows that a closer look into the cost and utility parameter can help to identify potential bias. Future simulation models should focus on integrating all relevant phases of care, using methodologically sound utility parameters and avoiding inconsistent cost parameters.

MARIA M4: clinical evaluation of a prototype ultrawideband radar scanner for breast cancer detection

A microwave imaging system has been developed as a clinical diagnostic tool operating in the 3- to 8-GHz region using multistatic data collection. A total of 86 patients recruited from a symptomatic breast care clinic were scanned with a prototype design. The resultant three-dimensional images have been compared "blind" with available ultrasound and mammogram images to determine the detection rate. Images show the location of the strongest signal, and this corresponded in both older and younger women, with sensitivity of [Formula: see text], which was found to be maintained in dense breasts. The pathway from clinical prototype to clinical evaluation is outlined.

Management of asymptomatic silicone-injected breast with reduction mammoplasty

Even though Silicone injection for breast augmentation has been related to disastrous long-term effects and complications, some patients do not develop significant symptoms at all (asymptomatic). Unfortunately, the management of asymptomatic Silicone-injected breast is still unclear and has never been reported exclusively. We present two cases of asymptomatic patients with a history of liquid Silicone injections who refused to have a mastectomy. They were concerned with the breast ptosis and chose to undergo reduction mammoplasty to improve the appearance of the breasts. Magnetic resonance imaging may be useful as an additional screening tool to confirm the diagnosis and exclude the presence of malignancy in breasts with injected Silicone. We believe that breast reduction may be the alternative option for women with a history of liquid Silicone injection who have no symptoms but desire to preserve their breasts and improve their aesthetics.

CEA in breast ductal secretions as a promising biomarker for the diagnosis of breast cancer: a systematic review and meta-analysis

PURPOSE

Other studies have shown that levels of carcinoembryonic antigen (CEA) in breast ductal secretions (BDS) differ significantly between breast cancer (BC) patients and healthy individuals, providing direct evidence for CEA in BDS as a promising biomarker for BC. This meta-analysis was designed to assess the potential diagnostic value of CEA in BDS.

METHODS

Relevant articles were retrieved from Embase, Pubmed, and the Cochrane Library. Sensitivity, specificity, and diagnostic odds ratio (DOR) of CEA in BDS for diagnosing BC were pooled using random effects models. SROC and the area under the curve (AUC) were used to estimate overall diagnostic performance.

RESULTS

This meta-analysis comprised five studies with a total of 340 BC patients and 448 healthy controls. For CEA in BDS, the pooled sensitivity, specificity, and DOR to diagnose BC were 58 % [95 % confidence interval (CI): 52-63 %], 87 % (95 % CI: 84-90 %), and 7.07 (95 % CI: 3.10-16.12), respectively. Moreover, the AUC of CEA in the diagnosis of BC was 0.8570.

CONCLUSIONS

CEA in BDS is a promising biomarker in the diagnosis of BC and should be evaluated as a standard screening tool upon verification of our results in a larger study population.

Abbreviated screening protocol for breast MRI: a feasibility study

RATIONALE AND OBJECTIVES

To compare the performance of two shortened breast magnetic resonance imaging (MRI) protocols to a standard MRI protocol for breast cancer screening.

MATERIALS AND METHODS

In this Health Insurance Portability and Accountability Act compliant, institutional review board-approved pilot study, three fellowship-trained breast imagers evaluated 48 breast MRIs (24 normal, 12 benign, and 12 malignant) selected from a high-risk screening population. MRIs were presented in three viewing protocols, and a final Breast Imaging-Reporting and Data System assessment was recorded for each case. The first shortened protocol (abbreviated 1) included only fat-saturated precontrast T2-weighted, precontrast T1-weighted, and first pass T1-weighted postcontrast sequences. The second shortened protocol (abbreviated 2) included the abbreviated 1 protocol plus the second pass T1-weighted postcontrast sequence. The third protocol (full), reviewed after a 1-month waiting period, included a nonfat-saturated T1-weighted sequence, fat-saturated T2-weighted, precontrast T1-weighted, and three or four dynamic postcontrast sequences. Interpretation times were recorded for the abbreviated 1 and full protocols. Sensitivity and specificity were compared via a chi-squared analysis. This pilot study was designed to detect a 10% difference in sensitivity with a power of 0.8.

RESULTS

There was no significant difference in sensitivity between the abbreviated 1 (86%; P = .22) or abbreviated 2 (89%; P = .38) protocols and the full protocol (95%). There was no significant difference in specificity between the abbreviated 1 (52%; P = 1) or abbreviated 2 (45%; P = .34) protocols and the full protocol (52%). The abbreviated 1 and full protocol interpretation times were similar (2.98 vs. 3.56 minutes).

CONCLUSIONS

In this pilot study, reader performance comparing two shortened breast MRI protocols to a standard protocol in a screening cohort were similar, suggesting that a shortened breast MRI protocol may be clinically useful, warranting further investigation.

Clinical management of women at high risk of breast cancer

PURPOSE OF REVIEW

This article reviews the evidence that underpins breast cancer screening and prevention strategies for women at high risk of the disease, with a particular focus on evidence published in the last 18 months. The review is timely because the US National Comprehensive Cancer Network, the UK National Institute for Health and Care Excellence and the American Society of Clinical Oncology have recently updated relevant guidelines that inform practice.

RECENT FINDINGS

In the recently published literature, there have been several important findings. A meta-analysis of randomized trials of selective oestrogen receptor modulators (SERMs), along with the first results from the International Breast Cancer Intervention Study II trial, further support the use of SERMs and aromatase inhibitors in the primary prevention of breast cancer. A large observational study has provided evidence that the SERM tamoxifen may be efficacious for breast cancer prevention in women who carry mutations in the breast cancer predisposition genes, BRCA1 and BRCA2. Several observational studies have suggested that contralateral risk-reducing mastectomy, following a diagnosis of breast cancer, may reduce mortality.

SUMMARY

Evidence regarding the optimal management of women at high risk of breast cancer continues to evolve and needs to be rapidly implemented into clinical practice.

MRI screening for breast cancer in women at high risk; is the Australian breast MRI screening access program addressing the needs of women at high risk of breast cancer?

Breast magnetic resonance imaging (MRI) screening of women under 50 years old at high familial risk of breast cancer was given interim funding by Medicare in 2009 on the basis that a review would be undertaken. An updated literature review has been undertaken by the Medical Services Advisory Committee but there has been no assessment of the quality of the screening or other screening outcomes. This review examines the evidence basis of breast MRI screening and how this fits within an Australian context with the purpose of informing future modifications to the provision of Medicare-funded breast MRI screening in Australia. Issues discussed will include selection of high-risk women, the options for MRI screening frequency and measuring the outcomes of screening.

What Are the Recommended Timing and Screening Modalities in Women at Higher Risk for Developing Breast Cancer? A Clin-IQ

Early detection of breast cancer is desirable to prevent progression to advanced disease. This subject has been one of significant study and debate for women at normal risk, and recommendations continue to evolve. However, with regard to women at high risk, the recommendations from various health care professional organizations, including the recent recommendations from the United States Preventative Services Task Force, are different and also inconsistent concerning when to begin screening and which modalities should be used. We review several randomized controlled trials and consensus opinions regarding when to begin screening for breast cancer and how to best screen women at high risk. Specifically, we address women with known personal history of breast cancer, prior mantle radiation, or specific family history (including genetic family history) of breast cancer. The purpose of this inquiry is to present current evidence and suggest a clinical pathway regarding the screening of women at high risk for breast cancer.