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McCarthy AM, Fernandez Perez C, Beidas RS, Bekelman JE, Blumenthal D, Mack E, Bauer AM, Ehsan S, Conant EF, Wheeler BC, Guerra CE, Nunes LW, Gabriel P, Doucette A, Wileyto EP, Buttenheim AM, Asch DA, Rendle KA, Shelton RC, Fayanju OM, Ware S, Plag M, Hyland S, Gionta T, Shulman LN, Schnoll R. Protocol for a pragmatic stepped wedge cluster randomized clinical trial testing behavioral economic implementation strategies to increase supplemental breast MRI screening among patients with extremely dense breasts. Implement Sci 2023; 18:65. [PMID: 38001506 PMCID: PMC10668465 DOI: 10.1186/s13012-023-01323-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics ("nudges") can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI. METHODS Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial's conclusion will examine barriers and facilitators to implementation. DISCUSSION This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection. TRIAL REGISTRATION ClinicalTrials.gov NCT05787249. Registered on March 28, 2023.
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Affiliation(s)
- Anne Marie McCarthy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | | | - Rinad S Beidas
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Justin E Bekelman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Daniel Blumenthal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Mack
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna-Marika Bauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Ehsan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily F Conant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carmen E Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Linda W Nunes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter Gabriel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Abigail Doucette
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E Paul Wileyto
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Alison M Buttenheim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Rachel C Shelton
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Oluwadamilola M Fayanju
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Sue Ware
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Martina Plag
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Hyland
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tracy Gionta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Robert Schnoll
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
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Lawson MB, Partridge SC, Hippe DS, Rahbar H, Lam DL, Lee CI, Lowry KP, Scheel JR, Parsian S, Li I, Biswas D, Bryant ML, Lee JM. Comparative Performance of Contrast-enhanced Mammography, Abbreviated Breast MRI, and Standard Breast MRI for Breast Cancer Screening. Radiology 2023; 308:e230576. [PMID: 37581498 PMCID: PMC10481328 DOI: 10.1148/radiol.230576] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 08/16/2023]
Abstract
Background Contrast-enhanced mammography (CEM) and abbreviated breast MRI (ABMRI) are emerging alternatives to standard MRI for supplemental breast cancer screening. Purpose To compare the diagnostic performance of CEM, ABMRI, and standard MRI. Materials and Methods This single-institution, prospective, blinded reader study included female participants referred for breast MRI from January 2018 to June 2021. CEM was performed within 14 days of standard MRI; ABMRI was produced from standard MRI images. Two readers independently interpreted each CEM and ABMRI after a washout period. Examination-level performance metrics calculated were recall rate, cancer detection, and false-positive biopsy recommendation rates per 1000 examinations and sensitivity, specificity, and positive predictive value of biopsy recommendation. Bootstrap and permutation tests were used to calculate 95% CIs and compare modalities. Results Evaluated were 492 paired CEM and ABMRI interpretations from 246 participants (median age, 51 years; IQR, 43-61 years). On 49 MRI scans with lesions recommended for biopsy, nine lesions showed malignant pathology. No differences in ABMRI and standard MRI performance were identified. Compared with standard MRI, CEM demonstrated significantly lower recall rate (14.0% vs 22.8%; difference, -8.7%; 95% CI: -14.0, -3.5), lower false-positive biopsy recommendation rate per 1000 examinations (65.0 vs 162.6; difference, -97.6; 95% CI: -146.3, -50.8), and higher specificity (87.8% vs 80.2%; difference, 7.6%; 95% CI: 2.3, 13.1). Compared with standard MRI, CEM had significantly lower cancer detection rate (22.4 vs 36.6; difference, -14.2; 95% CI: -28.5, -2.0) and sensitivity (61.1% vs 100%; difference, -38.9%; 95% CI: -66.7, -12.5). The performance differences between CEM and ABMRI were similar to those observed between CEM and standard MRI. Conclusion ABMRI had comparable performance to standard MRI and may support more efficient MRI screening. CEM had lower recall and higher specificity compared with standard MRI or ABMRI, offset by lower cancer detection rate and sensitivity compared with standard MRI. These trade-offs warrant further consideration of patient population characteristics before widespread screening with CEM. Clinical trial registration no. NCT03517813 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Chang in this issue.
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Affiliation(s)
- Marissa B. Lawson
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Savannah C. Partridge
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Daniel S. Hippe
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Habib Rahbar
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Diana L. Lam
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Christoph I. Lee
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Kathryn P. Lowry
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - John R. Scheel
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Sana Parsian
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Isabella Li
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Debosmita Biswas
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Mary Lynn Bryant
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
| | - Janie M. Lee
- From the Department of Radiology, University of Washington, Seattle,
Wash (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L., D.B., M.L.B., J.M.L.);
Department of Radiology (M.B.L., S.C.P., H.R., D.L.L., C.I.L., K.P.L., I.L.,
D.B., M.L.B., J.M.L.) and Clinical Research Division (D.S.H.), Fred Hutchinson
Cancer Center, 825 Eastlake Eve E, LG-200, Seattle, WA 98109; Department of
Radiology, Vanderbilt University, Nashville, Tenn (J.R.S.); and Department of
Radiology, Kaiser Permanente, Seattle, Wash (S.P.)
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