Risk factors for second screen-detected or interval breast cancers in women with a personal history of breast cancer participating in mammography screening

Breast cancer recurrence in relation to mode of detection: implications on personalized surveillance

PURPOSE

The effectiveness of current follow-up guidelines after breast cancer treatment is uncertain. Tailored surveillance based on patient age and tumor characteristics may be more adequate. This study aimed to analyze the frequency of ipsilateral locoregional recurrences (LR) and second primary breast cancers (SP) detected outside of scheduled surveillance and to analyze risk factors associated with these events.

METHODS

Patients with surgically treated early-stage breast cancer from the Malmö Diet and Cancer Study (MDCS), 1991-2014 (n = 1080), and the Västernorrland region, 2009-2018 (n = 1648), were included. Clinical and pathological information on the primary tumor and recurrences was retrieved from medical records. The mode of recurrence detection was defined as detection within (planned) or outside (symptomatic) of scheduled surveillance.

RESULTS

The median follow-up was 6.5 years. Overall, 461 patients experienced a recurrence. The most common initial event was distant metastasis (47%), followed by locoregional recurrence (LR) (22%) and second primary (SP) (18%). 56% of LR and 28% of SP were identified outside of scheduled surveillance. Logistic regression analysis revealed that younger age (under 50 years) (OR 2.57, 95% CI 1.04-6.88), lymph node-positive breast cancer (OR 2.10, 95% CI 1.03-4.39) and breast cancer of the HER2 positive subtype (OR 5.24, 95% CI 1.40-25.90) were correlated with higher odds of detecting a recurrence outside of planned surveillance.

CONCLUSION

Most recurrent events were detected outside of scheduled surveillance, particularly for locoregional recurrences. Risk-based surveillance, which takes into account patient and tumor characteristics, might be more suitable for specific patient subsets.

Second breast cancer following negative breast MRI: Analysis by interval from surgery and risk factors

OBJECTIVES

This study aims to compare outcomes following a negative surveillance MRI study by surgery-MRI interval and investigate factors associated with second breast cancers in women with a personal history of breast cancer (PHBC).

METHODS

This retrospective study included 1552 consecutive women (mean age, 53 years) with a PHBC and a negative prevalence surveillance breast MRI result between August 2014 and December 2016. The incidence and characteristics of second breast cancers were reviewed and compared according to surgery-MRI interval (< 3 years vs ≥ 3 years). Logistic regression analysis was used to investigate associations with clinical-pathologic characteristics.

RESULTS

Twenty-five second breast cancers occurred after negative MRI. The incidence of second breast cancers or local-regional recurrence did not significantly differ by surgery-MRI interval. The median intervals between MRI to second breast cancer detection showed no significant difference between the two groups (surgery-MRI interval <3 years vs. ≥ 3 years). Two node-positive second breast cancers were detected in the group with <3 years interval. BRCA mutation status, receipt of breast-conserving surgery, and adjuvant chemotherapy (all p < .05) were significant factors associated with the development of second breast cancers.

CONCLUSION

Outcomes following a negative surveillance MRI did not differ by surgery-MRI interval. BRCA mutation status, receipt of breast-conserving surgery and adjuvant chemotherapy were independently associated with the risk of developing second breast cancers after negative surveillance MRI.

Automated Breast Ultrasound Provides Comparable Diagnostic Performance in Opportunistic Screening and Diagnostic Assessment

OBJECTIVE

The aim of the work described here was to assess the performance of automated breast ultrasound (ABUS) as an adjunct to digital breast tomosynthesis (DBT) in the screening and diagnostic setting.

METHODS

This cross-sectional study of women who underwent DBT and ABUS from December 2019 to March 2022 included opportunistic and targeted screening cases, as well as symptomatic women. Breast density, Breast Imaging Reporting and Data System categories and histopathology reports were collected and compared. The PPV3 (proportion of examinations with abnormal findings that resulted in a tissue diagnosis of cancer), biopsy rate (percentage of biopsies performed) and cancer detection yield (number of malignancies found by the diagnostic test given to the study sample) were calculated.

RESULTS

A total of 1089 ABUS examinations were performed (age range: 29-85 y, mean: 51.9 y). Among these were 909 screening (83.5%) and 180 diagnostic (16.5%) examinations. A total of 579 biopsies were performed on 407 patients, with a biopsy rate of 53.2%. There were 100 (9.2%) malignant lesions, 30 (5.2%) atypical/B3 lesions and 414 (71.5%) benign cases. In 9 cases (0.08%), ABUS alone detected malignancies, and in 19 cases (1.7%), DBT alone detected malignancies. The PPV3 in the screening group was 14.6%.

CONCLUSION

ABUS is useful as an adjunct to DBT in the opportunistic screening and diagnostic setting.

Evaluation of Predict, a prognostic risk tool, after diagnosis of a second breast cancer

BACKGROUND

The UK National Health Service's Predict is a clinical tool widely used to estimate the prognosis of early-stage breast cancer. The performance of Predict for a second primary breast cancer is unknown.

METHODS

Women 18 years of age or older diagnosed with a first or second invasive breast cancer between 2000 and 2013 and followed for at least 5 years were identified from the US Surveillance, Epidemiology, and End Results (SEER) database. Model calibration of Predict was evaluated by comparing predicted and observed 5-year breast cancer-specific mortality separately by estrogen receptor status for first vs second breast cancer. Receiver operating characteristic curves and areas under the curve were used to assess model discrimination. Model performance was also evaluated for various races and ethnicities.

RESULTS

The study population included 6729 women diagnosed with a second breast cancer and 357 204 women with a first breast cancer. Overall, Predict demonstrated good discrimination for first and second breast cancers (areas under the curve ranging from 0.73 to 0.82). Predict statistically significantly underestimated 5-year breast cancer mortality for second estrogen receptor-positive breast cancers (predicted-observed = ‒6.24%, 95% CI = ‒6.96% to ‒5.49%). Among women with a first estrogen receptor-positive cancer, model calibration was good (predicted-observed = ‒0.22%, 95% CI = ‒0.29% to ‒0.15%), except in non-Hispanic Black women (predicted-observed = ‒2.33%, 95% CI = ‒2.65% to ‒2.01%) and women 80 years of age or older (predicted-observed = ‒3.75%, 95% CI = ‒4.12% to ‒3.41%). Predict performed well for second estrogen receptor-negative cancers overall (predicted-observed = ‒1.69%, 95% CI = ‒3.99% to 0.16%) but underestimated mortality among those who had previously received chemotherapy or had a first cancer with more aggressive tumor characteristics. In contrast, Predict overestimated mortality for first estrogen receptor-negative cancers (predicted-observed = 4.54%, 95% CI = 4.27% to 4.86%).

CONCLUSION

The Predict tool underestimated 5-year mortality after a second estrogen receptor-positive breast cancer and in certain subgroups of women with a second estrogen receptor-negative breast cancer.

Recommendations for the Screening of Breast Cancer of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Society of Mastology and Brazilian Federation of Gynecology and Obstetrics Association

OBJECTIVE

 To present the update of the recommendations of the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Society of Mastology and the Brazilian Federation of Associations of Gynecology and Obstetrics for breast cancer screening in Brazil.

METHODS

 Scientific evidence published in Medline, EMBASE, Cochrane Library, EBSCO, CINAHL and Lilacs databases between January 2012 and July 2022 was searched. Recommendations were based on this evidence by consensus of the expert committee of the three entities.

RECOMMENDATIONS

 Annual mammography screening is recommended for women at usual risk aged 40-74 years. Above 75 years, it should be reserved for those with a life expectancy greater than seven years. Women at higher than usual risk, including those with dense breasts, with a personal history of atypical lobular hyperplasia, classic lobular carcinoma in situ, atypical ductal hyperplasia, treatment for breast cancer or chest irradiation before age 30, or even, carriers of a genetic mutation or with a strong family history, benefit from complementary screening, and should be considered individually. Tomosynthesis is a form of mammography and should be considered in screening whenever accessible and available.

Recommendations for breast cancer screening in Brazil, from the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Society of Mastology, and the Brazilian Federation of Gynecology and Obstetrics Associations

Objective

To present an update of the recommendations of the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Society of Mastology, and the Brazilian Federation of Gynecology and Obstetrics Associations for breast cancer screening in Brazil.

Materials and Methods

Scientific evidence published between January 2012 and July 2022 was gathered from the following databases: Medline (PubMed); Excerpta Medica (Embase); Cochrane Library; Ebsco; Cumulative Index to Nursing and Allied Health Literature (Cinahl); and Latin-American and Caribbean Health Sciences Literature (Lilacs). Recommendations were based on that evidence and were arrived at by consensus of a joint committee of experts from the three entities.Recommendations: Annual mammographic screening is recommended for women between 40 and 74 years of age. For women at or above the age of 75, screening should be reserved for those with a life expectancy greater than seven years. Women at higher than average risk are considered by category: those with dense breasts; those with a personal history of atypical lobular hyperplasia, classical lobular carcinoma in situ, or atypical ductal hyperplasia; those previously treated for breast cancer; those having undergone thoracic radiotherapy before age 30; and those with a relevant genetic mutation or a strong family history. The benefits of complementary screening are also addressed according to the subcategories above. The use of tomosynthesis, which is an evolved form of mammography, should be considered in screening, whenever accessible and available.

Imaging Surveillance Options for Individuals With a Personal History of Breast Cancer: AJR Expert Panel Narrative Review

Annual surveillance mammography is recommended for breast cancer survivors on the basis of observational studies and meta-analyses showing reduced breast cancer mortality and improved quality of life. However, breast cancer survivors are at higher risk of subsequent breast cancer and have a fourfold increased risk of interval breast cancers compared with individuals without a personal history of breast cancer. Supplemental surveillance modalities offer increased cancer detection compared with mammography alone, but utilization is variable, and benefits must be balanced with possible harms of false-positive findings. In this review, we describe the current state of mammographic surveillance, summarize evidence for supplemental surveillance in breast cancer survivors, and explore a risk-based approach to selecting surveillance imaging strategies. Further research identifying predictors associated with increased risk of interval second breast cancers and development of validated risk prediction tools may help physicians and patients weigh the benefits and harms of surveillance breast imaging and decide on a personalized approach to surveillance for improved breast cancer outcomes.

ACR Appropriateness Criteria® Imaging After Breast Surgery

Given that 20% to 40% of women who have percutaneous breast biopsy subsequently undergo breast surgery, knowledge of imaging women with a history of benign (including high-risk) disease or breast cancer is important. For women who had surgery for nonmalignant pathology, the surveillance recommendations are determined by their overall risk. Higher-than-average risk women with a history of benign surgery may require screening mammography starting at an earlier age before 40 and may benefit from screening MRI. For women with breast cancer who have undergone initial excision and have positive margins, imaging with diagnostic mammography or MRI can sometimes guide additional surgical planning. Women who have completed breast conservation therapy for cancer should get annual mammography and may benefit from the addition of MRI or ultrasound to their surveillance regimen. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Screening MRI in Women at Intermediate Breast Cancer Risk: An Update of the Recent Literature

Guidelines issued by the American Cancer Society (ACS) in 2007 recommend neither for nor against screening MRI in women at intermediate breast cancer risk (15%-20%), including those with dense breast tissue, a history of lobular neoplasia or atypical ductal hyperplasia (ADH), or a prior breast cancer, because of scarce supporting evidence about the utility of MRI in these specific patient populations. However, since the issuance of the ACS guidelines in 2007, multiple investigations have found that women at intermediate risk may be suitable candidates for screening MRI, given the high detection rates of early-stage cancers and acceptable false-positive rates. For women with dense breast tissue, the Dense Tissue and Early Breast Neoplasm Screening trial reported that the incremental cancer detection rate (CDR) by MRI exceeded 16 cancers per 1000 examinations but decreased in the second round of screening; this decrease in CDR, however, occurred alongside a marked decrease in the false-positive rate. For women with lobular neoplasia or ADH, single-institution retrospective analyses have shown CDRs mostly ranging from 11 to 16 cancers per 1000 MRI examinations, with women with lobular carcinoma in situ benefitting more than women with atypical lobular hyperplasia or ADH. For patients with a prior breast cancer, the cancer yield by MRI varies widely but mostly ranges from 8 to 20 cancers per 1000 examinations, with certain subpopulations more likely to benefit, such as those with dense breasts. This article reviews and summarizes more recent studies on MRI screening of intermediate-risk women.

Classification of Breast Cancer Lesions in Ultrasound Images by Using Attention Layer and Loss Ensemble in Deep Convolutional Neural Networks

The reliable classification of benign and malignant lesions in breast ultrasound images can provide an effective and relatively low-cost method for the early diagnosis of breast cancer. The accuracy of the diagnosis is, however, highly dependent on the quality of the ultrasound systems and the experience of the users (radiologists). The use of deep convolutional neural network approaches has provided solutions for the efficient analysis of breast ultrasound images. In this study, we propose a new framework for the classification of breast cancer lesions with an attention module in a modified VGG16 architecture. The adopted attention mechanism enhances the feature discrimination between the background and targeted lesions in ultrasound. We also propose a new ensembled loss function, which is a combination of binary cross-entropy and the logarithm of the hyperbolic cosine loss, to improve the model discrepancy between classified lesions and their labels. This combined loss function optimizes the network more quickly. The proposed model outperformed other modified VGG16 architectures, with an accuracy of 93%, and also, the results are competitive with those of other state-of-the-art frameworks for the classification of breast cancer lesions. Our experimental results show that the choice of loss function is highly important and plays a key role in breast lesion classification tasks. Additionally, by adding an attention block, we could improve the performance of the model.

Screening Breast MRI Primer: Indications, Current Protocols, and Emerging Techniques

Breast dynamic contrast-enhanced MRI (DCE-MRI) is the most sensitive imaging modality for the detection of breast cancer. Screening MRI is currently performed predominantly in patients at high risk for breast cancer, but it could be of benefit in patients at intermediate risk for breast cancer and patients with dense breasts. Decreasing scan time and image interpretation time could increase cost-effectiveness, making screening MRI accessible to a larger group of patients. Abbreviated breast MRI (Ab-MRI) reduces scan time by decreasing the number of sequences obtained, but as multiple delayed contrast enhanced sequences are not obtained, no kinetic information is available. Ultrafast techniques rapidly acquire multiple sequences during the first minute of gadolinium contrast injection and provide information about both lesion morphology and vascular kinetics. Diffusion-weighted imaging is a noncontrast MRI technique with the potential to detect mammographically occult cancers. This review article aims to discuss the current indications of breast MRI as a screening tool, examine the standard breast DCE-MRI technique, and explore alternate screening MRI protocols, including Ab-MRI, ultrafast MRI, and noncontrast diffusion-weighted MRI, which can decrease scan time and interpretation time.

Breast cancer risk factors by mode of detection among screened women in the Cancer Prevention Study-II

BACKGROUND

Identifying risk factors for women at high risk of symptom-detected breast cancers that were missed by screening would enable targeting of enhanced screening regimens. To this end, we examined associations of breast cancer risk factors by mode of detection in screened women from the Cancer Prevention Study (CPS)-II Nutrition Cohort.

METHODS

Among 77,206 women followed for a median of 14.8 years, 2711 screen-detected and 1281 symptom-detected breast cancer cases were diagnosed. Multivariable-adjusted associations were estimated using joint Cox proportional hazards regression models with person-time calculated contingent on screening.

RESULTS

Factors associated with higher risks of symptom-detected and screen-detected breast cancer included current combined hormone therapy (HT) use (HR 2.07, 95% CI 1.72-2.48 and 1.45, 1.27-1.65, respectively) and history of benign breast disease (1.85, 1.64-2.08 and 1.43, 1.31-1.55, respectively). Current estrogen-only HT use was associated with symptom-detected (1.40, 1.15-1.71) but not screen-detected (0.95, 0.83-1.09) breast cancer. Higher risk of screen-detected but not symptom-detected breast cancer was observed for obese vs. normal body mass index (1.22, 1.01-1.48 and 0.76, 0.56-1.01, respectively), per 3 h/day sitting time (1.10, 1.04-1.16 and 0.97, 0.89-1.06, respectively), and ≥ 2 drinks per day vs. nondrinker (1.40, 1.16-1.69 and 1.27, 0.97-1.66, respectively).

CONCLUSIONS

Differences in risk factors for symptom-detected vs. screen-detected breast cancer were observed and most notably, use of combined and estrogen-only HT and a history of benign breast disease were associated with increased risk of symptomatic detected breast cancer.

IMPACT

If confirmed, these data suggest that such women may benefit from more intensive screening to facilitate early detection.

Influence of Breast Density on Patient's Compliance during Ultrasound Examination: Conventional Handheld Breast Ultrasound Compared to Automated Breast Ultrasound

Background:

Our aim was to study the influence of breast density on patient's compliance during conventional handheld breast ultrasound (US) or automated breast US (ABUS), which could be used as adjunct screening modalities.

Methods:

Between January 2019 and June 2019, 221 patients (mean age: 53; age range: 24–89 years) underwent both US and ABUS. All participants had independently interpreted US and ABUS regarding patient compliance. The diagnostic experience with US or ABUS was described with a modified testing morbidity index (TMI). The scale ranged from 0 (worst possible experience) to 5 (acceptable experience). Standard statistics was used to compare the data of US and data of ABUS. Breast density was recorded with the Breast Imaging Reporting and Data System (BI-RADS) score.

Results:

The mean TMI score was 4.6 ± 0.5 for US and 4.3 ± 0.8 for ABUS. The overall difference between patients' experience on US and ABUS was statistically significant with P < 0.0001. The difference between patients' experience on US and ABUS in women with BI-RADS C and D for breast density was statistically significant with P < 0.02 in favor of US (4.7 ± 0.4) versus 4.5 ± 0.6 for ABUS. Patients' experience with breast density B was better for US (4.7 ± 0.4) versus 4.3 ± 0.6 for ABUS with P < 0.01. Pain or discomfort occurred during testing, especially in patients >40 years.

Conclusion:

Patient age (>40 years) is a significant predictor of decreased compliance to ABUS. Compliance of ABUS resulted lower that of US independently for breast density.

Screening mammography for second breast cancers in women with history of early-stage breast cancer: factors and causes associated with non-detection

Background

The aim of our study was to identify the factors and causes associated with non-detection for second breast cancers on screening mammography in women with a personal history of early-stage breast cancer.

Methods

Between January 2000 and December 2008, 7976 women with early-stage breast cancer underwent breast surgery in our institution. The inclusion criteria of our study were patients who had: (a) subsequent in-breast recurrence, (b) surveillance mammography within 1 year before recurrence. Retrospective analysis of mammography was performed. Non-detection was defined as second breast cancers that were not visible on screening mammography. Imaging features, demographics, primary breast cancer (PBC) characteristics, and clinical features were evaluated to determine its association with non-detection. Univariate and multivariate logistic regression analyses were also performed to identify the factors related to non-detection.

Results

We identified 188 patients that met the criteria. Among them, 39% of patients showed non-detection (n = 74). Of the 74 patients with non-detection, 53 (72%) were classified as having no detectable mammographic abnormality (i.e., true negative) due to overlapping dense breast tissue (n = 32), obscured by postoperative scar (n = 12) or difficult anatomic location / poor positioning (n = 9). The remaining 21 patients were categorized as having subtle findings (n = 11) or missed cancer (n = 10). Non-detection for second breast cancers were significantly associated with mammographic breast density (p = 0.001, OR = 2.959) and detectability of PBC on mammography (p = 0.011, OR = 3.013).

Conclusion

Non-detection of second breast cancer in women with a personal history of early-stage breast cancer were associated with mammographic dense breast and lower detectability of PBC on mammography.

Breast imaging surveillance after curative treatment for primary non-metastasised breast cancer in non-high-risk women: a systematic review

OBJECTIVES

The article summarises the available guidelines on breast imaging surveillance after curative treatment for locoregional breast cancer.

METHODS

A systematic review of practice guidelines published from 1 January 2007 to 1 January 2017 was performed according to PRISMA methodology. The search was conducted for the EMBASE, MEDLINE, Cochrane and Centre for Reviews and Dissemination databases. On 8 July 2018, all included guidelines were updated to the most recent version.

RESULTS

Twenty-one guidelines originating from 18 publishing bodies matched criteria. Publishing bodies consisted of seven governmental institutions, nine medical societies and two mixed collaborations. Publishing boards consisted of six radiological, four oncological, and 11 multidisciplinary teams. Annual bilateral mammography surveillance after breast-conserving therapy was recommended by 17/18 (94.4%) publishing bodies. Annual contralateral mammography surveillance after mastectomy was recommended by 13/18 (72.2%) publishing bodies. Routine use of digital breast tomosynthesis was recommended by 1/18 (5.6%) publishing bodies. Routine breast ultrasound surveillance was recommended by 2/18 (11.1%), deemed optional by 4/18 (22.2%) and not supported by 8/18 (44.4%) publishing bodies. Routine breast magnetic resonance imaging (MRI) surveillance was not recommended by 16/18 (88.9%) publishing bodies, although 6/18 (33.3%) specified subgroups for systematic MRI surveillance.

CONCLUSIONS

Annual mammography is currently the 'gold standard' for breast imaging surveillance. The role of digital breast tomosynthesis (DBT) remains to be further investigated. Most guidelines do not recommend routine breast ultrasound or MRI surveillance, unless indicated by additional risk factors.

Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 1 with Recommendations for the Screening, Diagnosis and Therapy of Breast Cancer

Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Methods The process of updating the S3 guideline dating from 2012 was based on the adaptation of identified source guidelines which were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and the results of a systematic search of literature databases and the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point to develop recommendations and statements which were modified and graded in a structured consensus procedure. Recommendations Part 1 of this short version of the guideline presents recommendations for the screening, diagnosis and follow-up care of breast cancer. The importance of mammography for screening is confirmed in this updated version of the guideline and forms the basis for all screening. In addition to the conventional methods used to diagnose breast cancer, computed tomography (CT) is recommended for staging in women with a higher risk of recurrence. The follow-up concept includes suggested intervals between physical, ultrasound and mammography examinations, additional high-tech diagnostic procedures, and the determination of tumor markers for the evaluation of metastatic disease.

Cumulative Risk Distribution for Interval Invasive Second Breast Cancers After Negative Surveillance Mammography

Purpose The aim of the current study was to characterize the risk of interval invasive second breast cancers within 5 years of primary breast cancer treatment. Methods We examined 65,084 surveillance mammograms from 18,366 women with a primary breast cancer diagnosis of unilateral ductal carcinoma in situ or stage I to III invasive breast carcinoma performed from 1996 to 2012 in the Breast Cancer Surveillance Consortium. Interval invasive breast cancer was defined as ipsilateral or contralateral cancer diagnosed within 1 year after a negative surveillance mammogram. Discrete-time survival models-adjusted for all covariates-were used to estimate the probability of interval invasive cancer, given the risk factors for each surveillance round, and aggregated across rounds to estimate the 5-year cumulative probability of interval invasive cancer. Results We observed 474 surveillance-detected cancers-334 invasive and 140 ductal carcinoma in situ-and 186 interval invasive cancers which yielded a cancer detection rate of 7.3 per 1,000 examinations (95% CI, 6.6 to 8.0) and an interval invasive cancer rate of 2.9 per 1,000 examinations (95% CI, 2.5 to 3.3). Median cumulative 5-year interval cancer risk was 1.4% (interquartile range, 0.8% to 2.3%; 10th to 90th percentile range, 0.5% to 3.7%), and 15% of women had ≥ 3% 5-year interval invasive cancer risk. Cumulative 5-year interval cancer risk was highest for women with estrogen receptor- and progesterone receptor-negative primary breast cancer (2.6%; 95% CI, 1.7% to 3.5%), interval cancer presentation at primary diagnosis (2.2%; 95% CI, 1.5% to 2.9%), and breast conservation without radiation (1.8%; 95% CI, 1.1% to 2.4%). Conclusion Risk of interval invasive second breast cancer varies across women and is influenced by characteristics that can be measured at initial diagnosis, treatment, and imaging. Risk prediction models that evaluate the risk of cancers not detected by surveillance mammography should be developed to inform discussions of tailored surveillance.

Screening women with a personal history of breast cancer: overview of the evidence on breast imaging surveillance

This work reviews the evidence on breast imaging for screening (surveillance) in women with a history of breast cancer (BC). Early detection of second BCs in these women improves their prognosis based on studies using mammography (usually with clinical examinations) for surveillance. Cohort studies have estimated that mammography surveillance has moderate sensitivity (65.4%) and good specificity (98.3%), and have shown that these women are at a higher risk of interval BC than age- and breast density-matched women without a history of BC. Studies of adjunct imaging (ultrasound, magnetic resonance imaging) for surveillance that have reported detection and accuracy measures have generally shown that adjunct imaging detected more second BCs than mammography and added substantially to the amount of false-positive results; however, little evidence exists regarding screening efficacy of adjunct imaging as part of routine surveillance.

Incidence and Outcome of Breast Biopsy Procedures During Follow-up After Treatment for Breast Cancer

Importance

No comprehensive data are available regarding the frequency of breast biopsies performed during follow-up of treatment for invasive breast cancer.

Objective

To determine how often patients treated for breast cancer require breast biopsies during follow-up.

Design, Setting, and Participants

This nationwide population-based cohort study included 41 510 patients 64 years or younger in a commercial insurance database and 80 369 patients 66 years or older in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Patients were diagnosed with incident invasive breast cancer (stages I-III) from January 1, 2000, through December 31, 2011. Diagnosis and procedural codes were used to identify biopsy rates during follow-up. Data were analyzed from March 3 through October 3, 2017.

Main Outcomes and Measures

Cumulative incidence and adjusted risk of breast biopsy and subsequent breast cancer treatment were calculated using the Kaplan-Meier method and Cox proportional hazards regression. All statistical tests were 2 sided.

Results

Among the 121 879 patients in the study population, 5- and 10-year overall incidences of breast biopsy were 14.7% and 23.4%, respectively, in the commercial insurance cohort and 11.8% and 14.9%, respectively, in the SEER-Medicare cohort. The 5-year estimated incidence of breast biopsy was higher among women treated with brachytherapy (24.0% in the commercial insurance and 25.0% in the SEER-Medicare cohorts) than among those treated with whole-breast irradiation (16.7% in the commercial insurance and 15.1% in the SEER-Medicare cohorts) and persisted after multivariate adjustment in the commercial insurance (hazard ratio [HR], 1.53; 95% CI, 1.38-1.70; P < .001) and SEER-Medicare (HR, 1.76; 95% CI, 1.63-1.91; P < .001) cohorts. Adjuvant chemotherapy use (HR, 1.31; 95% CI, 1.25-1.37; P < .001) and patient age (>85 vs 66-69 years; HR, 0.40; 95% CI, 0.36-0.44; P < .001) in the SEER-Medicare cohort and endocrine therapy in the commercial insurance (HR, 0.88; 95% CI, 0.82-0.93; P < .001) and SEER-Medicare (HR, 0.91; 95% CI, 0.85-0.97; P = .002) cohorts were independently associated with biopsy. After unilateral mastectomy, the estimated 5-year contralateral breast biopsy rates were 10.4% and 7.7% in the commercial insurance and SEER-Medicare cohorts, respectively. Of the patients with breast biopsy, 1239 of 4158 patients (29.8%) in the commercial insurance cohort and 2258 of 9747 patients (23.2%) in the SEER-Medicare cohort underwent subsequent cancer treatment.

Conclusions and Relevance

These data on the need for breast biopsies during follow-up and subsequent treatments from a large cohort of women with commercial insurance and Medicare can be used in the context of therapy-planning discussions and survivorship expectations for patients with breast cancer.

Predictors of surveillance mammography outcomes in women with a personal history of breast cancer

PURPOSE

To identify predictors of poor mammography surveillance outcomes based on clinico-pathologic features.

METHODS

This study was HIPAA compliant and IRB approved. We performed an electronic medical record review for a cohort of women with American Joint Committee on Cancer (AJCC) Stage I or II invasive breast cancer treated with breast conservation therapy who developed subsequent in-breast treatment recurrence (IBTR) or contralateral breast cancer (CBC). Poor surveillance outcome was defined as second breast cancer not detected by surveillance mammography, including interval cancers (diagnosed within 365 days of surveillance mammogram with negative results) and clinically detected cancers (diagnosed without a surveillance mammogram in the preceding 365 days). Univariate and multivariate logistic regression were performed to identify predictors of poor mammography surveillance outcome, including patient and primary tumor characteristics, breast density, mode of primary tumor detection, and time to second cancer diagnosis.

RESULTS

164 women met inclusion criteria (65 with IBTR, 99 with CBC); 124 had screen-detected second cancers. On univariate analysis, poor surveillance outcome (n = 40) was associated with age at primary cancer diagnosis < 50 years (p < 0.0001), AJCC stage II primary cancers (p = 0.007), and heterogeneously or extremely dense breasts (p = 0.04). On multivariate analysis, age < 50 years at primary breast cancer diagnosis remained a significant predictor of poor surveillance outcome (p = 0.001).

CONCLUSION

Women younger than age 50 at primary breast cancer diagnosis are at risk of poor surveillance mammography outcomes, and may be appropriate candidates for more intensive clinical and imaging surveillance.

Diagnostic performances of supplemental breast ultrasound screening in women with personal history of breast cancer

Background Supplemental breast ultrasonography (US) has been used as a surveillance imaging method in women with personal history of breast cancer (PHBC). However, there have been limited data regarding diagnostic performances. Purpose To evaluate diagnostic performances of supplemental breast US screening for women with PHBC and to compare with those for women without PHBC. Material and Methods Between 2011 and 2012, 12,230 supplemental US exams were performed in 12,230 women with negative mammograms: 6584 women with PHBC and 5646 women without PHBC. Cancer detection rate, interval cancer rate, abnormal interpretation rate, positive predictive values (PPVs), sensitivity, and specificity were calculated and compared. Results Overall cancer detection rate and first-year interval cancer rate were 1.80/1000 exams and 0.91/1000 negative exams, both of which were higher in women with PHBC than in women without PHBC (2.88 vs. 0.53 per 1000, P = 0.003; 1.50 vs. 0.20 per 1000, P = 0.027). Abnormal interpretation rate was lower in the women with PHBC than in women without PHBC (9.1% vs. 12.1%, P < 0.001). Sensitivity was not different (67.9% vs. 75.0%, P = 1.000), whereas specificity and PPV₃ were higher in women with PHBC than in women without PHBC (91.2% vs. 88.0%, P < 0.001; 22.6% vs. 3.1%, P < 0.001). The majority of detected cancers in women with PHBC (78.9%, 15/19) were stage 0 or 1. Conclusion Supplemental breast US screening increases early stage second breast cancers with high specificity and PPV₃ in women with PHBC, however, high interval cancer rate in younger women with PHBC should be noted.

Breast Biopsy Intensity and Findings Following Breast Cancer Screening in Women With and Without a Personal History of Breast Cancer

IMPORTANCE

There is little evidence on population-based harms and benefits of screening breast magnetic resonance imaging (MRI) in women with and without a personal history of breast cancer (PHBC).

OBJECTIVE

To evaluate biopsy rates and yield in the 90 days following screening (mammography vs magnetic resonance imaging with or without mammography) among women with and without a PHBC.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 6 Breast Cancer Surveillance Consortium (BCSC) registries. Population-based sample of 812 164 women undergoing screening, 2003 through 2013.

EXPOSURES

A total of 2 048 994 digital mammography and/or breast MRI screening episodes (mammogram alone vs MRI with or without screening mammogram within 30 days).

MAIN OUTCOMES AND MEASURES

Biopsy intensity (surgical greater than core greater than fine-needle aspiration) and yield (invasive cancer greater than ductal carcinoma in situ greater than high-risk benign greater than benign) within 90 days of a screening episode. We computed age-adjusted rates of biopsy intensity (per 1000 screening episodes) and biopsy yield (per 1000 screening episodes with biopsies). Outcomes were stratified by PHBC and by BCSC 5-year breast cancer risk among women without PHBC.

RESULTS

We included 101 103 and 1 939 455 mammogram screening episodes in women with and without PHBC, respectively; MRI screening episodes included 3763 with PHBC and 4673 without PHBC. Age-adjusted core and surgical biopsy rates (per 1000 episodes) doubled (57.1; 95% CI, 50.3-65.1) following MRI compared with mammography (23.6; 95% CI, 22.4-24.8) in women with PHBC. Differences (per 1000 episodes) were even larger in women without PHBC: 84.7 (95% CI, 75.9-94.9) following MRI and 14.9 (95% CI, 14.7-15.0) following mammography episodes. Ductal carcinoma in situ and invasive biopsy yield (per 1000 episodes) was significantly higher following mammography compared with MRI episodes in women with PHBC (mammography, 404.6; 95% CI, 381.2-428.8; MRI, 267.6; 95% CI, 208.0-337.8) and nonsignificantly higher, but in the same direction, in women without PHBC (mammography, 279.3; 95% CI, 274.2-284.4; MRI, 214.6; 95% CI, 158.7-280.8). High-risk benign lesions were more commonly identified following MRI regardless of PHBC. Higher biopsy rates and lower cancer yield following MRI were not explained by increasing age or higher 5-year breast cancer risk.

CONCLUSIONS AND RELEVANCE

Women with and without PHBC who undergo screening MRI experience higher biopsy rates coupled with significantly lower cancer yield findings following biopsy compared with screening mammography alone. Further work is needed to identify women who will benefit from screening MRI to ensure an acceptable benefit-to-harm ratio.

Breast Cancer Screening With Mammography Plus Ultrasonography or Magnetic Resonance Imaging in Women 50 Years or Younger at Diagnosis and Treated With Breast Conservation Therapy

Importance

Younger women (aged ≤50 years) who underwent breast conservation therapy may benefit from breast magnetic resonance imaging (MRI) screening as an adjunct to mammography.

Objective

To prospectively determine the cancer yield and tumor characteristics of combined mammography with MRI or ultrasonography screening in women who underwent breast conservation therapy for breast cancers and who were 50 years or younger at initial diagnosis.

Design, Setting, and Participants

This multicenter, prospective, nonrandomized study was conducted from December 1, 2010, to January 31, 2016, at 6 academic institutions. Seven hundred fifty-four women who were 50 years or younger at initial diagnosis and who had undergone breast conservation therapy for breast cancer were recruited to participate in the study. Reference standard was defined as a combination of pathology and 12-month follow-up.

Interventions

Participants underwent 3 annual MRI screenings of the conserved and contralateral breasts in addition to mammography and ultrasonography, with independent readings.

Main Outcomes and Measures

Cancer detection rate, sensitivity, specificity, interval cancer rate, and characteristics of detected cancers.

Results

A total of 754 women underwent 2065 mammograms, ultrasonography, and MRI screenings. Seventeen cancers were diagnosed, and most of the detected cancers (13 of 17 [76%]) were stage 0 or stage 1. Overall cancer detection rate (8.2 vs 4.4 per 1000; P = .003) or sensitivity (100% vs 53%; P = .01) of mammography with MRI was higher than that of mammography alone. After the addition of ultrasonography, the cancer detection rate was higher than that by mammography alone (6.8 vs 4.4 per 1000; P = .03). The specificity of mammography with MRI or ultrasonography was lower than that by mammography alone (87% or 88% vs 96%; P < .001). No interval cancer was found.

Conclusions and Relevance

After breast conservation therapy in women 50 years or younger, the addition of MRI to annual mammography screening improves detection of early-stage but biologically aggressive breast cancers at acceptable specificity. Results from this study can inform patient decision making on screening methods after breast conservation therapy.

Breast cancer screening: updated recommendations of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Breast Disease Society, and Brazilian Federation of Gynecological and Obstetrical Associations

Objective

To present the current recommendations for breast cancer screening in Brazil, as devised by the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Breast Disease Society, and the Brazilian Federation of Gynecological and Obstetrical Associations.

Materials and methods

We analyzed scientific studies available in the Medline and Lilacs databases. In the absence of evidence, the recommendations reflected the consensus of a panel of experts.

Recommendations

Annual mammography screening is recommended for women 40-74 years of age. Among women ≥ 75 years of age, annual mammography screening should be reserved for those with an expected survival > 7 years. Complementary ultrasound should be considered for women with dense breasts. Complementary magnetic resonance imaging is recommended for women at high risk. When available, an advanced form of mammography known as tomosynthesis can be considered as a means of screening for breast cancer.

Imaging Surveillance After Primary Breast Cancer Treatment

OBJECTIVE

Current clinical guidelines are consistent in supporting annual mammography for women after treatment of primary breast cancer. Surveillance imaging beyond standard digital mammography, including digital breast tomosynthesis (DBT), breast ultrasound, and MRI, may improve outcomes. This article reviews the evidence on the performance and effectiveness of breast imaging modalities available for surveillance after treatment of sporadic unilateral primary breast cancer and identifies additional factors to be considered when selecting an imaging surveillance regimen.

CONCLUSION

Evidence review supports the use of mammography for surveillance after primary breast cancer treatment. Variability exists in guideline recommendations for surveillance initiation, interval, and cessation. DBT offers the most promise as a potential modality to replace standard digital mammography as a front-line surveillance test; a single published study to date has shown a significant decrease in recall rates compared with standard digital mammography alone. Most guidelines do not support the use of whole-breast ultrasound in breast cancer surveillance, and further studies are needed to define the characteristics of women who may benefit from MRI surveillance. The emerging evidence about surveillance imaging outcomes suggests that additional factors, including patient and imaging characteristics, tumor biology and gene expression profile, and choice of treatment, warrant consideration in selecting personalized posttreatment imaging surveillance regimens.

A model for individualized risk prediction of contralateral breast cancer

PURPOSE

Patients diagnosed with invasive breast cancer (BC) or ductal carcinoma in situ are increasingly choosing to undergo contralateral prophylactic mastectomy (CPM) to reduce their risk of contralateral BC (CBC). This is a particularly disturbing trend as a large proportion of these CPMs are believed to be medically unnecessary. Many BC patients tend to substantially overestimate their CBC risk. Thus, there is a pressing need to educate patients effectively on their CBC risk. We develop a CBC risk prediction model to aid physicians in this task.

METHODS

We used data from two sources: Breast Cancer Surveillance Consortium and Surveillance, Epidemiology, and End Results to build the model. The model building steps are similar to those used in developing the BC risk assessment tool (popularly known as Gail model) for counseling women on their BC risk. Our model, named CBCRisk, is exclusively designed for counseling women diagnosed with unilateral BC on the risk of developing CBC.

RESULTS

We identified eight factors to be significantly associated with CBC-age at first BC diagnosis, anti-estrogen therapy, family history of BC, high-risk pre-neoplasia status, estrogen receptor status, breast density, type of first BC, and age at first birth. Combining the relative risk estimates with the relevant hazard rates, CBCRisk projects absolute risk of developing CBC over a given period.

CONCLUSIONS

By providing individualized CBC risk estimates, CBCRisk may help in counseling of BC patients. In turn, this may potentially help alleviate the rate of medically unnecessary CPMs.

Strategies to Increase Cancer Detection: Review of True-Positive and False-Negative Results at Digital Breast Tomosynthesis Screening

Digital breast tomosynthesis (DBT) represents a valuable addition to breast cancer screening by decreasing recall rates while increasing cancer detection rates. The increased accuracy achieved with DBT is due to the quasi-three-dimensional format of the reconstructed images and the ability to "scroll through" breast tissue in the reconstructed images, thereby reducing the effect of tissue superimposition found with conventional planar digital mammography. The margins of both benign and malignant lesions are more conspicuous at DBT, which allows improved lesion characterization, increased reader confidence, and improved screening outcomes. However, even with the improvements in accuracy achieved with DBT, there remain differences in breast cancer conspicuity by mammographic view. Early data suggest that breast cancers may be more conspicuous on craniocaudal (CC) views than on mediolateral oblique (MLO) views. While some very laterally located breast cancers may be visualized on only the MLO view, the increased conspicuity of cancers on the CC view compared with the MLO view suggests that DBT screening should be performed with two-view imaging. Even with the improved conspicuity of lesions at DBT, there may still be false-negative studies. Subtle lesions seen on only one view may be discounted, and dense and/or complex tissue patterns may make some cancers occult or extremely difficult to detect. Therefore, radiologists should be cognizant of both perceptual and cognitive errors to avoid potential pitfalls in lesion detection and characterization. ^©RSNA, 2016 Online supplemental material is available for this article.

The utility of linked cancer registry and health administration data for describing system-wide outcomes and research: a BreastScreen example

RATIONALE, AIMS AND OBJECTIVES

Stratification of women with screen-detected ductal carcinoma in situ (DCIS) by risk of subsequent invasive breast cancer (IBC) could assist treatment planning and selection of surveillance protocols that accord with risk. We assessed the utility of routinely collected administrative data for stratifying by IBC risk following DCIS detection in a population-based screening programme to inform ongoing surveillance protocols.

METHODS

A retrospective cohort design was used, employing linked data from the South Australian breast screening programme and cancer registry. Women entered the study at screening commencement and were followed until IBC diagnosis, death or end of the study period (1 December 2010), whichever came first. Routinely collected administrative data were analyzed to identify predictors of invasive breast cancer.

RESULTS

Proportional hazards regression confirmed that the DCIS cohort had an elevated risk of IBC after adjustment for relevant confounders (HR = 4.0 (95% CL 3.4, 4.8)), which accorded with previous study results. Within the DCIS cohort, conservative breast surgery and earlier year of screening commencement were both predictive of an elevated invasive breast cancer risk.

CONCLUSIONS

These linked cancer registry and administrative data gave plausible estimates of IBC risk following DCIS diagnosis, but were limited in coverage of key items for further risk stratification. It is important that the research utility of administrative datasets is maximized in their design phase in collaboration with researchers.

Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts: Interim Report of a Prospective Comparative Trial

PURPOSE

Debate on adjunct screening in women with dense breasts has followed legislation requiring that women be informed about their mammographic density and related adjunct imaging. Ultrasound or tomosynthesis can detect breast cancer (BC) in mammography-negative dense breasts, but these modalities have not been directly compared in prospective trials. We conducted a trial of adjunct screening to compare, within the same participants, incremental BC detection by tomosynthesis and ultrasound in mammography-negative dense breasts.

PATIENTS AND METHODS

Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts is a prospective multicenter study recruiting asymptomatic women with mammography-negative screens and dense breasts. Eligible women had tomosynthesis and physician-performed ultrasound with independent interpretation of adjunct imaging. Outcome measures included cancer detection rate (CDR), number of false-positive (FP) recalls, and incremental CDR for each modality; these were compared using McNemar's test for paired binary data in a preplanned interim analysis.

RESULTS

Among 3,231 mammography-negative screening participants (median age, 51 years; interquartile range, 44 to 78 years) with dense breasts, 24 additional BCs were detected (23 invasive): 13 tomosynthesis-detected BCs (incremental CDR, 4.0 per 1,000 screens; 95% CI, 1.8 to 6.2) versus 23 ultrasound-detected BCs (incremental CDR, 7.1 per 1,000 screens; 95% CI, 4.2 to 10.0), P = .006. Incremental FP recall occurred in 107 participants (3.33%; 95% CI, 2.72% to 3.96%). FP recall (any testing) did not differ between tomosynthesis (FP = 53) and ultrasound (FP = 65), P = .26; FP recall (biopsy) also did not differ between tomosynthesis (FP = 22) and ultrasound (FP = 24), P = .86.

CONCLUSION

The Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts' interim analysis shows that ultrasound has better incremental BC detection than tomosynthesis in mammography-negative dense breasts at a similar FP-recall rate. However, future application of adjunct screening should consider that tomosynthesis detected more than 50% of the additional BCs in these women and could potentially be the primary screening modality.

Breast cancer screening using tomosynthesis in combination with digital mammography compared to digital mammography alone: a cohort study within the PROSPR consortium

Digital breast tomosynthesis (DBT) is emerging as the new standard of care for breast cancer screening based on improved cancer detection coupled with reductions in recall compared to screening with digital mammography (DM) alone. However, many prior studies lack follow-up data to assess false negatives examinations. The purpose of this study is to assess if DBT is associated with improved screening outcomes based on follow-up data from tumor registries or pathology. Retrospective analysis of prospective cohort data from three research centers performing DBT screening in the PROSPR consortium from 2011 to 2014 was performed. Recall and biopsy rates were assessed from 198,881 women age 40-74 years undergoing screening (142,883 DM and 55,998 DBT examinations). Cancer, cancer detection, and false negative rates and positive predictive values were assessed on examinations with one year of follow-up. Logistic regression was used to compare DBT to DM adjusting for research center, age, prior breast imaging, and breast density. There was a reduction in recall with DBT compared to DM (8.7 vs. 10.4 %, p < 0.0001), with adjusted OR = 0.68 (95 % CI = 0.65-0.71). DBT demonstrated a statistically significant increase in cancer detection over DM (5.9 vs. 4.4/1000 screened, adjusted OR = 1.45, 95 % CI = 1.12-1.88), an improvement in PPV1 (6.4 % for DBT vs. 4.1 % for DM, adjusted OR = 2.02, 95 % CI = 1.54-2.65), and no significant difference in false negative rates for DBT compared to DM (0.46 vs. 0.60/1000 screened, p = 0.347). Our data support implementation of DBT screening based on increased cancer detection, reduced recall, and no difference in false negative screening examinations.

Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society

IMPORTANCE

Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality.

OBJECTIVE

To update the American Cancer Society (ACS) 2003 breast cancer screening guideline for women at average risk for breast cancer.

PROCESS

The ACS commissioned a systematic evidence review of the breast cancer screening literature to inform the update and a supplemental analysis of mammography registry data to address questions related to the screening interval. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms.

EVIDENCE SYNTHESIS

Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health. Estimates of the cumulative lifetime risk of false-positive examination results are greater if screening begins at younger ages because of the greater number of mammograms, as well as the higher recall rate in younger women. The quality of the evidence for overdiagnosis is not sufficient to estimate a lifetime risk with confidence. Analysis examining the screening interval demonstrates more favorable tumor characteristics when premenopausal women are screened annually vs biennially. Evidence does not support routine clinical breast examination as a screening method for women at average risk.

RECOMMENDATIONS

The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).

CONCLUSIONS AND RELEVANCE

These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer. These recommendations should be considered by physicians and women in discussions about breast cancer screening.

Five-year risk of interval-invasive second breast cancer

BACKGROUND

Earlier detection of second breast cancers after primary breast cancer (PBC) treatment improves survival, yet mammography is less accurate in women with prior breast cancer. The purpose of this study was to examine women presenting clinically with second breast cancers after negative surveillance mammography (interval cancers), and to estimate the five-year risk of interval-invasive second cancers for women with varying risk profiles.

METHODS

We evaluated a prospective cohort of 15 114 women with 47 717 surveillance mammograms diagnosed with stage 0-II unilateral PBC from 1996 through 2008 at facilities in the Breast Cancer Surveillance Consortium. We used discrete time survival models to estimate the association between odds of an interval-invasive second breast cancer and candidate predictors, including demographic, PBC, and imaging characteristics. All statistical tests were two-sided.

RESULTS

The cumulative incidence of second breast cancers after five years was 54.4 per 1000 women, with 325 surveillance-detected and 138 interval-invasive second breast cancers. The five-year risk of interval-invasive second cancer for women with referent category characteristics was 0.60%. For women with the most and least favorable profiles, the five-year risk ranged from 0.07% to 6.11%. Multivariable modeling identified grade II PBC (odds ratio [OR] = 1.95, 95% confidence interval [CI] = 1.15 to 3.31), treatment with lumpectomy without radiation (OR = 3.27, 95% CI = 1.91 to 5.62), interval PBC presentation (OR = 2.01, 95% CI 1.28 to 3.16), and heterogeneously dense breasts on mammography (OR = 1.54, 95% CI = 1.01 to 2.36) as independent predictors of interval-invasive second breast cancers.

CONCLUSIONS

PBC diagnosis and treatment characteristics contribute to variation in subsequent-interval second breast cancer risk. Consideration of these factors may be useful in developing tailored post-treatment imaging surveillance plans.

Clinicopathologic features and time interval analysis of contralateral breast cancers

INTRODUCTION

We hypothesized that most contralateral breast cancers (CBCs) develop ≥5 years after the primary breast cancer (PBC) and that CBCs have more favorable tumor characteristics.

METHODS

This is a single-institution retrospective review of 323 patients who were diagnosed with CBC from 1990 to 2014. CBCs were diagnosed at least 1 year after the diagnosis of PBC. Χ(2) tests and one-way analysis of variance were used to examine the time interval and pathologic features between the PBC and CBC.

RESULTS

The median time interval between the PBC and CBC was 6.2 years (average: 7.1, range: 1.01-23.0), and 189 (58.5%) patients had a time interval ≥5 years. Patients ≥70 years old developed a CBC sooner than patients <50 years (median: 4.3 vs 6.6 years, P < .001). Patients with infiltrating lobular carcinoma developed their CBC in 9.0 years versus 6.2 years for infiltrating ductal carcinoma histology (P = .028). In comparison with the PBC, a greater proportion of CBCs were stage I (50.8%), T1 (72.1%), node negative (67.5%), and estrogen receptor positive (68.7%). Of the 252 patients with available tumor size information for both cancers, only 54 (21.4%) patients developed a CBC that was >1 cm larger than their PBC, and only 25 (9.9%) patients developed a CBC that was >2 cm larger than their PBC. Only 28 of 201 (13.9%) node-negative PBCs developed a node-positive CBC.

CONCLUSION

A majority of CBCs develop ≥5 years after the diagnosis of the PBC. CBCs have more favorable tumor characteristics than the PBC and tend to be smaller and node negative.

Breast cancer screening: Evidence of the effect of adjunct ultrasound screening in women with unilateral mammography-negative dense breasts

BACKGROUND

Patients with the previous history of breast cancer are in risk of contralateral breast cancer. On the other hand, increased breast density is a risk factor for breast cancer and the sensitivity of detecting nonpalpable cancers in screening mammography in radiographically dense breasts is low. The use of ultrasonography in dense breast remains a controversial topic. The purpose of this study was to assess the usefulness of routine ultrasonography in follow-up of women with the previous history of breast cancer and negative mammography but dense breasts.

MATERIALS AND METHODS

In a cross-sectional study, a total of 267 individuals with unilateral postmastectomy mammogram screened and 153 subjects assigned to study. There were 28 subjects with American College of Radiology (ACR) breast density 2 and 125 with ACR breast density 3-4, which there was no new finding in their mammogram in comparison to previous studies. We assumed subjects with ACR breast density 3-4 as mammographic Breast Imaging Reporting and Data System (BI-RADS) category 0 for malignancy. Standard two-view mammogram was performed for all participants, and breast ultrasound (US) examinations were performed by an expert radiologist in radial and anti-radial planes. The data were analyzed using SPSS version 20.0 (SPSS Inc., Chicago, Illinois, USA).

RESULTS

The results showed that in subjects with ACR breast density 3-4, when there was no new density in two consecutive mammograms in comparison to previous studies, US also showed no possibility for malignancy (BI-RADS 1-2). And also in subjects with ACR breast density 2, when the mammographic results were BI-RADS 1-2, the US results was the same.

CONCLUSION

Our data indicate that for the detection of breast cancer, sensitivity of US was not greater than mammography in patients with postmastectomy unilateral dense breast if there is not any new density.

Long-term surveillance mammography and mortality in older women with a history of early stage invasive breast cancer

Annual surveillance mammograms in older long-term breast cancer survivors are recommended, but this recommendation is based on little evidence and with no guidelines on when to stop. Surveillance mammograms should decrease breast cancer mortality by detecting second breast cancer events at an earlier stage. We examined the association between surveillance mammography beyond 5 years after diagnosis on breast cancer-specific mortality in a cohort of women aged ≥ 65 years diagnosed 1990-1994 with early stage breast cancer. Our cohort included women who survived disease free for ≥ 5 years (N = 1,235) and were followed from year 6 through death, disenrollment, or 15 years after diagnosis. Asymptomatic surveillance mammograms were ascertained through medical record review. We used Cox proportional hazards regression stratified by follow-up year to calculate the association between time-varying surveillance mammography and breast cancer-specific and other-than-breast mortality adjusting for site, stage, primary surgery type, age and time-varying Charlson Comorbidity Index. The majority (85 %) of the 1,235 5-year breast cancer survivors received ≥ 1 surveillance mammogram in years 5-9 (yearly proportions ranged from 48 to 58 %); 82 % of women received ≥ 1 surveillance mammogram in years 10-14. A total of 120 women died of breast cancer and 393 women died from other causes (average follow-up 7.3 years). Multivariable models and lasagna plots suggested a modest reduction in breast cancer-specific mortality with surveillance mammogram receipt in the preceding year (IRR 0.82, 95 % CI 0.56-1.19, p = 0.29); the association with other-cause mortality was 0.95 (95 % CI 0.78-1.17, p = 0.64). Among older breast cancer survivors, surveillance mammography may reduce breast cancer-specific mortality even after 5 years of disease-free survival. Continuing surveillance mammography in older breast cancer survivors likely requires physician-patient discussions similar to those recommended for screening, taking into account comorbid conditions and life-expectancy.