Tailored supplemental screening for breast cancer: what now and what next?

Clinicopathological characteristics and prognostic significance of casting-type calcifications in patients with invasive breast cancer presenting with microcalcification

To explore the clinicopathological characteristics and prognostic significance of casting-type calcification (CC) in patients with breast cancer presenting with microcalcification on mammography. Data on patients with invasive breast cancer who had mammographic calcification was retrospectively analyzed. The chi-square test was utilized to assess the clinicopathological characteristics of two forms of CC-related breast cancer. The examination of prognostic variables was conducted using Kaplan-Meier and Cox regression analyses. A total of 427 eligible patients were included in this study. Chi-square analysis indicated that the presence of CC was associated with estrogen receptor (ER) negativity (P = 0.005), progesterone receptor (PR) negativity (P < 0.001), and epidermal growth factor receptor 2 (HER-2) positivity (P < 0.001); among these, the association was stronger with the CC-predominant type. After a median follow-up of 82 months, those with CC had a worse 5-year recurrence-free survival (RFS) (77.1% vs. 86.9%, p = 0.036; hazard ratio [HR], 1.86; 95% confidence interval [CI] 1.04-3.31) and overall survival (OS) (84.0% vs. 94.4%, p = 0.007; HR, 2.99; 95% CI 1.34-6.65) rates. In COX regression analysis, such differences were still observed in HER-2 positive subgroups (RFS: HR: 2.45, 95% CI 1-5.97, P = 0.049; OS: HR: 4.53, 95% CI 1.17-17.52, P = 0.029). In patients with invasive breast cancer exhibiting calcifications on mammography, the presence of CC, especially the CC-predominant type, is linked to a higher frequency of hormone receptor negativity and HER-2 positivity. The presence of CC is associated with an unfavorable 5-year RFS and OS rates.

Extracellular vesicle-mediated drug delivery in breast cancer theranostics

Breast cancer (BC) continues to be a significant global challenge due to drug resistance and severe side effects. The increasing prevalence is alarming, requiring new therapeutic approaches to address these challenges. At this point, Extracellular vesicles (EVs), specifically small endosome-released nanometer-sized EVs (SEVs) or exosomes, have been explored by literature as potential theranostics. Therefore, this review aims to highlight the therapeutic potential of exosomes in BC, focusing on their advantages in drug delivery and their ability to mitigate metastasis. Following the review, we identified exosomes' potential in combination therapies, serving as miRNA carriers and contributing to improved anti-tumor effects. This is evident in clinical trials investigating exosomes in BC, which have shown their ability to boost chemotherapy efficacy by delivering drugs like paclitaxel (PTX) and doxorubicin (DOX). However, the translation of EVs into BC therapy is hindered by various challenges. These challenges include the heterogeneity of EVs, the selection of the appropriate parent cell, the loading procedures, and determining the optimal administration routes. Despite the promising therapeutic potential of EVs, these obstacles must be addressed to realize their benefits in BC treatment.

Comparative analysis of automated breast volume scanner (ABVS) combined with conventional hand-held ultrasound and mammography in female breast cancer detection

Objective and background

This study aimed to compare the diagnostic value of an automated breast volume scanner (ABVS) combined with conventional hand-held ultrasound and mammography in detecting female breast cancer. Early detection is vital in improving patient outcomes for this prevalent disease.

Methods

Seventy-eight suspicious breast lesions from 60 patients were examined between August 2019 and July 2020. Each patient underwent ABVS, conventional hand-held ultrasound, and mammography. Diagnostic values, including coincidence rate, sensitivity, specificity, positive predictive value, and negative predictive value, were calculated using histopathology results as the "gold standard."

Results

Histopathology confirmed 55 malignant (70.51%) and 23 benign lesions (29.48%). ABVS combined with conventional hand-held ultrasound identified 56 malignant (52 confirmed, 4 benign) and 22 benign nodules (3 confirmed, 19 benign). Mammography detected 48 malignant (45 confirmed, 3 benign) and 30 benign nodules (10 confirmed, 20 benign). ABVS combined with conventional hand-held ultrasound had a sensitivity of 94.5%, specificity of 82.6%, positive predictive value of 92.9%, and negative predictive value of 86.4%. Mammography showed a sensitivity of 81.8%, specificity of 87.0%, positive predictive value of 93.8%, and negative predictive value of 66.7%.

Conclusion

ABVS combined with conventional hand-held ultrasound showed high diagnostic value in detecting female breast cancer. The "convergence sign" in the coronal section played a significant role. It slightly outperformed mammography and offered advantages in terms of cost, convenience, comfort, and absence of radiation. Further promotion and implementation are supported.

TRPML1 as a potential therapeutic target for triple-negative breast cancer: a review

Triple-negative breast cancer (TNBC) is the most refractory subtype of breast cancer, and effective treatments are urgently needed owing to its poor prognosis. Surgery, radiotherapy, and chemotherapy, alone or in combination, are the leading choices for TNBC therapy. Although promising approaches and procedures have emerged, several challenges, such as off-target effects, drug resistance, and severe side effects, remain to be addressed. Recently, transient receptor potential channel mucolipin 1 (TRPML1) has attracted the attention of researchers because its expression has been implicated in numerous diseases, including cancer. TRPML1 regulates biological events and signaling pathways, including autophagic flux, exocytosis, ionic homeostasis, and lysosomal biogenesis, all contributing to tumorigenesis and cancer progression. TRPML1 also functions as a building block for cancer cell growth, mitogenic signaling, priming tissues for metastasis, and activation of transcriptional programs, processes involved in several malignant tumors. This review provides an overview of breast cancer epidemiology and diagnostic techniques and then discusses the existing therapeutics. Additionally, we elaborate on the development of, and associated challenges to, TNBC diagnostics and treatment and the feasibility of TRPML1 as a therapeutic target for TNBC.

Comparative Analysis of Diagnostic Performance of Automatic Breast Ultrasound, Full-Field Digital Mammography and Contrast-Enhanced Mammography in Relation to Breast Composition

This single center study includes a comparative analysis of the diagnostic performance of full-field digital mammography (FFDM), contrast-enhanced mammography (CEM) and automatic breast ultrasound (ABUS) in the group of patients with breast American College of Radiology (ACR) categories C and D as well as A and B with FFDM. The study involved 297 patients who underwent ABUS and FFDM. Breast types C and D were determined in 40% of patients with FFDM and low- energy CEM. CEM was performed on 76 patients. Focal lesions were found in 131 patients, of which 115 were histopathologically verified. The number of lesions detected in patients with multiple lesions were 40 from 48 with ABUS, 13 with FFDM and 21 with CEM. Compliance in determining the number of foci was 82% for FFDM and 91% for both CEM and ABUS. In breast types C and D, 72% of all lesions were found with ABUS, 56% with CEM and 29% with FFDM (p = 0.008, p = 0.000); all invasive cancers were diagnosed with ABUS, 83% with CEM and 59% with FFDM (p = 0.000, p = 0.023); 100% DCIS were diagnosed with ABUS, 93% with CEM and 59% with FFDM. The size of lesions from histopathology in breast ACR categories A and B was 14-26 mm, while in breast categories C and D was 11-37 mm. In breast categories C and D, sensitivity of ABUS, FFDM and CEM was, respectively, 78.05, 85.37, 92.68; specificity: 40, 13.33, 8.33; PPV (positive predictive value): 78.05, 72.92, 77.55; NPV (negative predictive value): 40, 25, 25, accuracy: 67.86, 66.07, 73.58. In breast categories A and B, sensitivity of ABUS, FFDM and CEM was, respectively, 81.25, 93.75, 93.48; specificity: 18.18, 18.18, 16.67; PPV: 81.25, 83.33, 89.58; NPV: 18.18, 40, 25; accuracy: 69.49, 79.66, 84.62. The sensitivity of the combination of FFDM and ABUS was 100 for all types of breast categories; the accuracy was 75 in breast types C and D and 81.36 in breast types A and B. The study confirms the predominance of C and D breast anatomy types and the low diagnostic performance of FFDM within that group and indicates ABUS and CEM as potential additive methods in breast cancer diagnostics.

Implementing the National Dense Breast Reporting Standard, Expanding Supplemental Screening Using Current Guidelines, and the Proposed Find It Early Act

Thirty-eight states and the District of Columbia (DC) have dense breast notification laws that mandate varying levels of patient notification about breast density after a mammogram, and these cover over 90% of American women. On March 10, 2023, the Food and Drug Administration issued a final rule amending regulations under the Mammography Quality Standards Act for a national dense breast reporting standard for both patient results letters and mammogram reports. Effective September 10, 2024, letters will be required to tell a woman her breasts are "dense" or "not dense," that dense tissue makes it harder to find cancers on a mammogram, and that it increases the risk of developing cancer. Women with dense breasts will also be told that other imaging tests in addition to a mammogram may help find cancers. The specific density category can be added (eg, if mandated by a state "inform" law). Reports to providers must include the Breast Imaging Reporting and Data System density category. Implementing appropriate supplemental screening should be based on patient risk for missed breast cancer on mammography; such assessment should include consideration of breast density and other risk factors. This article discusses strategies for implementation. Currently 21 states and DC have varying insurance laws for supplemental breast imaging; in addition, Oklahoma requires coverage for diagnostic breast imaging. A federal insurance bill, the Find It Early Act, has been introduced that would ensure no-cost screening and diagnostic imaging for women with dense breasts or at increased risk and close loopholes in state laws.

Breast Cancer Screening and Diagnosis: Recent Advances in Imaging and Current Limitations

Breast cancer detection has a significant impact on population health. Although there are many breast imaging modalities, mammography is the predominant tool for breast cancer screening. The introduction of digital breast tomosynthesis to mammography has contributed to increased cancer detection rates and decreased recall rates. In average-risk women, starting annual screening mammography at age 40 years has demonstrated the highest mortality reduction. In intermediate- and high-risk women as well as in those with dense breasts, additional modalities, including MRI, ultrasound, and molecular breast imaging, can also be considered for adjunct screening to improve the detection of mammographically occult malignancy.

Prospective Multicenter Diagnostic Performance of Technologist-Performed Screening Breast Ultrasound After Tomosynthesis in Women With Dense Breasts (the DBTUST)

PURPOSE

To assess diagnostic performance of digital breast tomosynthesis (DBT) alone or combined with technologist-performed handheld screening ultrasound (US) in women with dense breasts.

METHODS

In an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant multicenter protocol in western Pennsylvania, 6,179 women consented to three rounds of annual screening, interpreted by two radiologist observers, and had appropriate follow-up. Primary analysis was based on first observer results.

RESULTS

Mean participant age was 54.8 years (range, 40-75 years). Across 17,552 screens, there were 126 cancer events in 125 women (7.2/1,000; 95% CI, 5.9 to 8.4). In year 1, DBT-alone cancer yield was 5.0/1,000, and of DBT+US, 6.3/1,000, difference 1.3/1,000 (95% CI, 0.3 to 2.1; P = .005). In years 2 + 3, DBT cancer yield was 4.9/1,000, and of DBT+US, 5.9/1,000, difference 1.0/1,000 (95% CI, 0.4 to 1.5; P < .001). False-positive rate increased from 7.0% for DBT in year 1 to 11.5% for DBT+US and from 5.9% for DBT in year 2 + 3 to 9.7% for DBT+US (P < .001 for both). Nine cancers were seen only by double reading DBT and one by double reading US. Ten interval cancers (0.6/1,000 [95% CI, 0.2 to 0.9]) were identified. Despite reduction in specificity, addition of US improved receiver operating characteristic curves, with area under receiver operating characteristic curve increasing from 0.83 for DBT alone to 0.92 for DBT+US in year 1 (P = .01), with smaller improvements in subsequent years. Of 6,179 women, across all 3 years, 172/6,179 (2.8%) unique women had a false-positive biopsy because of DBT as did another 230/6,179 (3.7%) women because of US (P < .001).

CONCLUSION

Overall added cancer detection rate of US screening after DBT was modest at 19/17,552 (1.1/1,000; CI, 0.5- to 1.6) screens but potentially overcomes substantial increases in false-positive recalls and benign biopsies.

Diagnostic Performance of PET/MRI in Breast Cancer: A Systematic Review and Bayesian Bivariate Meta-analysis

INTRODUCTION

By performing a systematic review and meta-analysis, the diagnostic value of ¹⁸F-FDG PET/MRI in breast lesions, lymph nodes, and distant metastases was assessed, and the merits and demerits of PET/MRI in the application of breast cancer were comprehensively reviewed.

METHODS

Breast cancer-related studies using ¹⁸F-FDG PET/MRI as a diagnostic tool published before September 12, 2022 were included. The pooled sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under the curve (AUC) were calculated using Bayesian bivariate meta-analysis in a lesion-based and patient-based manner.

RESULTS

We ultimately included 24 studies (including 1723 patients). Whether on a lesion-based or patient-based analysis, PET/MRI showed superior overall pooled sensitivity (0.95 [95% CI: 0.92-0.98] & 0.93 [95% CI: 0.88-0.98]), specificity (0.94 [95% CI: 0.90-0.97] & 0.94 [95% CI: 0.92-0.97]), LDOR (5.79 [95% CI: 4.95-6.86] & 5.64 [95% CI: 4.58-7.03]) and AUC (0.98 [95% CI: 0.94-0.99] & 0.98[95% CI: 0.92-0.99]) for diagnostic applications in breast cancer. In the specific subgroup analysis, PET/MRI had high pooled sensitivity and specificity for the diagnosis of breast lesions and distant metastatic lesions and was especially excellent for bone lesions. PET/MRI performed poorly for diagnosing axillary lymph nodes but was better than for lymph nodes at other sites (pooled sensitivity, specificity, LDOR, AUC: 0.86 vs. 0.58, 0.90 vs. 0.82, 4.09 vs. 1.98, 0.89 vs. 0.84).

CONCLUSION

¹⁸F-FDG PET/MRI performed excellently in diagnosing breast lesions and distant metastases. It can be applied to the initial diagnosis of suspicious breast lesions, accurate staging of breast cancer patients, and accurate restaging of patients with suspected recurrence.

Addressing Disparities Related to Access of Multimodality Breast Imaging Services Before and During the COVID-19 Pandemic

Despite technological advancements focused on reducing breast cancer mortality through early detection, there have been reported disparities in the access to these imaging services with underserved patient populations (including racial minority groups and patients of low socioeconomic status) showing underutilization compared to other patient groups. These underserved populations tend to have more advanced breast cancer presentations, in part due to delays in diagnosis resulting in later stage of disease presentation. To make matters worse, the COVID-19 pandemic declared in March 2020 has resulted in significant healthcare disruptions leading to extensive delays in breast imaging services which are expected to negatively impact breast cancer mortality long-term. Given the worsening disparity in breast cancer mortality among racial/ethnic minorities and financially disadvantaged groups, it is vital to address these disparity gaps with the goal of reducing the barriers to timely breast cancer diagnosis and addressing breast cancer mortality differences among breast cancer patients. Therefore, this review aims to provide a discussion highlighting the disparities related to breast imaging access, the effects of the COVID-19 pandemic on these disparities, current targeted interventions implemented in breast imaging practices to reduce these disparities, and future directions on the journey to reducing disparity gaps for breast imaging patients. Tackling the root cause factors of the persistent breast cancer-related disparities is critical to meeting the needs of patients who are disadvantaged and can lead to continued improvement in the quality of individualized care for patients who have higher breast cancer morbidity and mortality risks.

Breast cancer diagnosis using frequency decomposition of surface motion of actuated breast tissue

This paper presents a computationally simple diagnostic algorithm for breast cancer using a non-invasive Digital Image Elasto Tomography (DIET) system. N=14 women (28 breasts, 13 cancerous) underwent a clinical trial using the DIET system following mammography diagnosis. The screening involves steady state sinusoidal vibrations applied to the free hanging breast with cameras used to capture tissue motion. Image reconstruction methods provide surface displacement data for approximately 14,000 reference points on the breast surface. The breast surface was segmented into four radial and four vertical segments. Frequency decomposition of reference point motion in each segment were compared. Segments on the same vertical band were hypothesised to have similar frequency content in healthy breasts, with significant differences indicating a tumor, based on the stiffness dependence of frequency and tumors being 4~10 times stiffer than healthy tissue. Twelve breast configurations were used to test robustness of the method. Optimal breast configuration for the 26 breasts analysed (13 cancerous, 13 healthy) resulted in 85% sensitivity and 77% specificity. Combining two opposite configurations resulted in correct diagnosis of all cancerous breasts with 100% sensitivity and 69% specificity. Bootstrapping was used to fit a smooth receiver operator characteristic (ROC) curve to compare breast configuration performance with optimal area under the curve (AUC) of 0.85. Diagnostic results show diagnostic accuracy is comparable or better than mammography, with the added benefits of DIET screening, including portability, non-invasive screening, and no breast compression, with potential to increase screening participation and equity, improving outcomes for women.

The Impact of Dense Breasts on the Stage of Breast Cancer at Diagnosis: A Review and Options for Supplemental Screening

The purpose of breast cancer screening is to find cancers early to reduce mortality and to allow successful treatment with less aggressive therapy. Mammography is the gold standard for breast cancer screening. Its efficacy in reducing mortality from breast cancer was proven in randomized controlled trials (RCTs) conducted from the early 1960s to the mid 1990s. Panels that recommend breast cancer screening guidelines have traditionally relied on the old RCTs, which did not include considerations of breast density, race/ethnicity, current hormone therapy, and other risk factors. Women do not all benefit equally from mammography. Mortality reduction is significantly lower in women with dense breasts because normal dense tissue can mask cancers on mammograms. Moreover, women with dense breasts are known to be at increased risk. To provide equity, breast cancer screening guidelines should be created with the goal of maximizing mortality reduction and allowing less aggressive therapy, which may include decreasing the interval between screening mammograms and recommending consideration of supplemental screening for women with dense breasts. This review will address the issue of dense breasts and the impact on the stage of breast cancer at the time of diagnosis, and discuss options for supplemental screening.

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.

Dependability of Automated Breast Ultrasound (ABUS) in Assessing Breast Imaging Reporting and Data System (BI-RADS) Category and Size of Malignant Breast Lesions Compared with Handheld Ultrasound (HHUS) and Mammography (MG)

Purpose

This study aimed to evaluate the dependability of automated breast ultrasound (ABUS) compared with handheld ultrasound (HHUS) and mammography (MG) on the Breast Imaging Reporting and Data System (BI-RADS) category and size assessment of malignant breast lesions.

Patients and Methods

A total of 344 confirmed malignant lesions were recruited. All participants underwent MG, HHUS, and ABUS examinations. Agreements on the BI-RADS category were evaluated. Lesion size assessed using the three methods was compared with the size of the pathological result as the control. Regarding the four major molecular subtypes, correlation coefficients between size on imaging and pathology were also evaluated.

Results

The agreement between ABUS and HHUS on the BI-RADS category was 86.63% (kappa = 0.77), whereas it was 32.22% (kappa = 0.10) between ABUS and MG. Imaging lesion size compared to pathologic lesion size was assessed correctly in 36.92%/52.91% (ABUS), 33.14%/48.84% (HHUS) and 33.44%/43.87% (MG), with the threshold of 3 mm/5 mm, respectively. The correlation coefficient of size of ABUS-Pathology (0.75, Spearman) was statistically higher than that of the MG-Pathology (0.58, Spearman) with P < 0.01, but not different from that of the HHUS-Pathology (0.74, Spearman) with P > 0.05. The correlation coefficient of ABUS-Pathology was statistically higher than that of MG-Pathology in the triple-negative subtype, luminal B subtype, and luminal A subtype (P<0.01).

Conclusion

The agreement between ABUS and HHUS in the BI-RADS category was good, whereas that between ABUS and MG was poor. ABUS and HHUS allowed a more accurate assessment of malignant tumor size compared to MG.

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

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

Modeling viscous damping in actuated breast tissue to provide diagnostic insight for breast cancer: A proof-of-concept analysis

PURPOSE

This study develops a viscous damping model (VDM) based on Rayleigh Damping (RD) with potential use in low cost, non-invasive breast cancer diagnostics using Digital Image Elasto Tomography (DIET).

METHODS

A clinical trial involving 13 subjects, each with a tumor in one breast, resulted in 13 cancerous and 13 healthy breasts. Displacement data following actuator induced steady state vibration in the breast tissue were captured using the DIET system. Over 14 000 reference points on the breast surface were split into four segments and viscous damping constant calculated for each reference point. The VDM was fit to median-filtered data for each breast segment and VDM coefficients compared within each breast. One model coefficient, relating to stiffness, was hypothesized to differ in breast segments containing a tumor. Comparison of " b " coefficients in different breast segments using percentage tolerances provided an unbiased, generalizable diagnostic method. Bootstrapping with replacement was used to upsample the data and create smooth receiver operator characteristic (ROC) curves. A total of 12 breast segmentation configurations were used to demonstrate the robustness of the method.

RESULTS

Fitting the VDM to median-filtered data gave consistent results for one VDM coefficient (" a ") across all breasts. The second VDM coefficient (" b ") showed diagnostic potential with breast segments having consistent coefficients in healthy breasts. In cancerous breasts " b " coefficients were found to be statistically different in segments containing and adjacent to the tumor compared with the segment furthest from the tumor with p < 0.02 using the Student t-Test. Large discrepancies in " b " coefficients were found to be indicative of a tumor with a 14.5% tolerance resulting in sensitivity and specificity of 76.9%. The optimal breast configuration resulted in an area under the ROC curve (AUC) of 0.81 with sensitivity and specificity at 77% and 72%, respectively.

CONCLUSION

This VDM method enables a computationally simple diagnostic technique using DIET for comfortable breast screening for women of all ages. Regular screening potential allows for tolerance alteration based on age, prior subject-specific results, and other risk factors to manage false positives, reducing psychological harm while optimizing early detection for successful treatment and decreased mortality.

The Role of Imaging in Health Screening: Screening for Specific Conditions

There are well-established and emerging screening examinations aimed at identifying malignant and nonmalignant conditions at early, treatable stages. The Radiology Research Alliance's "Role of Imaging in Health Screening" Task Force provides a comprehensive review of specific imaging-based screening examinations. This work reviews and serves as a reference for screening examinations for breast and colon cancer in a healthy population along with screening for lung cancer, hepatocellular carcinoma, and the use of whole body magnetic resonance imaging in at-risk individuals. American College of Radiology scoring systems, along with case-based examples, are included to illustrate the different disease entities. The future of screening is discussed, particularly in the context of artificial intelligence.

A Prospective Pilot Study on Use of Liquid Crystal Thermography to Detect Early Breast Cancer

Background: Breast cancer is the most common cancer in women. While mammography is the standard for early detection in women older than 50 years of age, there is no standard for younger women. The aim of this prospective pilot study was to assess liquid crystal contact thermography, using the Braster device, as a means for the early detection of breast cancer. The device is intended to be used as a complementary tool to standard of care (sonography, mammography, etc). Patients and Methods: A total of 274 consecutive women presenting at Polish breast centers for prophylactic breast examination were enrolled to receive thermography; 19 were excluded for errors in thermographic image acquisition. The women were divided according to age (n = 135, <50 years; n = 120, ≥50 years). A control population was included (n = 40, <50 years; n = 23, ≥50 years). The primary endpoint, stratified by age group, was the C-statistic for discrimination between breast cancer and noncancer. Results: In women with abnormal breast ultrasound (n = 95, <50 years; n = 87, ≥50 years), the C-statistic was 0.85 and 0.75, respectively (P = .20), for discrimination between breast cancer and noncancer. Sensitivity did not differ (P = .79) between the younger (82%) and older women (78%), while specificity was lower in the older women (60% vs 87%, P = .025). The false-positive rate was similar in women with normal and abnormal breast ultrasound. Positive thermographic result in women with Breast Imaging Reporting and Data System (BIRADS) 4A on ultrasound increased the probability of breast cancer by over 2-fold. Conversely, a negative thermographic result decreased the probability of cancer more than 3-fold. Breast size and structure did not affect the thermography performance. No adverse events were observed. Conclusions: Thermography performed well in women <50 years of age, while its specificity in women ≥50 years was inadequate. These promising findings suggest that the Braster device deserves further investigation as a supporting tool for the early detection of breast cancer in women younger than 50 years of age.

Screening Algorithms in Dense Breasts: AJR Expert Panel Narrative Review

Screening mammography reduces breast cancer mortality; however, when used to examine women with dense breasts, its performance and resulting benefits are reduced. Increased breast density is an independent risk factor for breast cancer. Digital breast tomosynthesis (DBT), ultrasound (US), molecular breast imaging (MBI), MRI, and contrast-enhanced mammography (CEM) each have shown improved cancer detection in dense breasts when compared with 2D digital mammography (DM). DBT is the preferred mammographic technique for producing a simultaneous reduction in recalls (i.e., additional imaging). US further increases cancer detection after DM or DBT and reduces interval cancers (cancers detected in the interval between recommended screening examinations), but it also produces substantial additional false-positive findings. MBI improves cancer detection with an effective radiation dose that is approximately fourfold that of DM or DBT but is still within accepted limits. MRI provides the greatest increase in cancer detection and reduces interval cancers and late-stage disease; abbreviated techniques will reduce cost and improve availability. CEM appears to offer performance similar to that of MRI, but further validation is needed. Dense breast notification will soon be a national standard; therefore, understanding the performance of mammography and supplemental modalities is necessary to optimize screening for women with dense breasts.

Automated breast ultrasound: Supplemental screening for average-risk women with dense breasts

OBJECTIVE

We review ultrasound (US) options for supplemental breast cancer screening of average risk women with dense breasts.

CONCLUSION

Performance data of physician-performed handheld US (HHUS), technologist-performed HHUS, and automated breast ultrasound (AUS) indicate that all are appropriate for adjunctive screening. Volumetric 3D acquisitions, reduced operator dependence, protocol standardization, reliable comparison with previous studies, independence of performance and interpretation, and whole breast depiction on coronal view may favor selection of AUS. Important considerations are workflow adjustments for physicians and staff.

Characterization of a multi-pinhole molecular breast tomosynthesis scanner

In recent years, breast imaging using radiolabelled molecules has attracted significant interest. Our group has proposed a multi-pinhole molecular breast tomosynthesis (MP-MBT) scanner to obtain 3D functional molecular breast images at high resolutions. After conducting extensive optimisation studies using simulations, we here present a first prototype of MP-MBT and evaluate its performance using physical phantoms. The MP-MBT design is based on two opposing gamma cameras that can image a lightly compressed pendant breast. Each gamma camera consists of a 250 × 150 mm² detector equipped with a collimator with multiple pinholes focusing on a line. The NaI(Tl) gamma detector is a customised design with 3.5 mm intrinsic spatial resolution and high spatial linearity near the edges due to a novel light-guide geometry and the use of square PMTs. A volume-of-interest is scanned by translating the collimator and gamma detector together in a sequence that optimises count yield from the scan region. Derenzo phantom images showed that the system can reach 3.5 mm resolution for a clinically realistic ^99mTc activity concentration in an 11-minute scan, while in breast phantoms the smallest spheres visible were 6 mm in diameter for the same scan time. To conclude, the experimental results of the novel MP-MBT scanner showed that the setup had sub-centimetre breast tumour detection capability which might facilitate 3D molecular breast cancer imaging in the future.

Comparison of automated versus hand-held breast US in supplemental screening in asymptomatic women with dense breasts: is there a difference regarding woman preference, lesion detection and lesion characterization?

PURPOSE

To compare automated breast volumetric scanning (ABVS) with hand-held bilateral whole breast ultrasound (HHUS) prospectively in regards to patient workflow, woman preference, efficacy in lesion detection, and characterization.

MATERIALS AND METHODS

Supplemental screening was performed with both ABVS and HHUS to 345 women with dense breasts and negative mammograms. Acquisition and evaluation times were recorded. Lesions were classified according to BIRADS US criteria and compared one to one. Women were recalled for a secondary HHUS examination if ABVS showed any additional lesions. Findings were compared based on biopsy results and/or 36-48 months of follow-up.

RESULTS

Findings could be compared for 340 women. There were two carcinomas which were detected by both methods, with no interval cancers in the follow-up period. Recall rate was 46/340 (13.05%) for ABVS and 4/340 (1.18%) for HHUS. ABVS recalls decreased with experience. HHUS had more true negative (BIRADS 1-2) results, while ABVS had more false positive ones (p < 0.001). Positive predictive value was 4.17% for ABVS and 50% for HHUS. ABVS overdiagnosed shadowings (p < 0.01), distortions (p < 0.034), and irregular nodules (p < 0.001) in comparison to HHUS. At ABVS, 10.6% of women experienced severe pain. 59.7% stated that they would choose HHUS if they had the chance.

CONCLUSION

ABVS is as good as HHUS in lesion detection. However, the recall rate is higher and positive predictive value is lower with ABVS, which could result in more follow-ups, and more anxiety for the women. More than 50% women stated they would prefer HHUS if they were given the chance.

Screening Breast Ultrasound Using Handheld or Automated Technique in Women with Dense Breasts

In women with dense breasts (heterogeneously or extremely dense), adding screening ultrasound to mammography increases detection of node-negative invasive breast cancer. Similar incremental cancer detection rates averaging 2.1-2.7 per 1000 have been observed for physician- and technologist-performed handheld ultrasound (HHUS) and automated ultrasound (AUS). Adding screening ultrasound (US) for women with dense breasts significantly reduces interval cancer rates. Training is critical before interpreting examinations for both modalities, and a learning curve to achieve optimal performance has been observed. On average, about 3% of women will be recommended for biopsy on the prevalence round because of screening US, with a wide range of 2%-30% malignancy rates for suspicious findings seen only on US. Breast Imaging Reporting and Data System 3 lesions identified only on screening HHUS can be safely followed at 1 year rather than 6 months. Computer-aided detection and diagnosis software can augment performance of AUS and HHUS; ongoing research on machine learning and deep learning algorithms will likely improve outcomes and workflow with screening US.

The Impact of Breast Density Notification Laws on Supplemental Breast Imaging and Breast Biopsy

BACKGROUND

Dense breast tissue increases breast cancer risk and lowers mammography sensitivity, but the value of supplemental imaging for dense breasts remains uncertain. Since 2009, 37 states and Washington DC have passed legislation requiring patient notification about breast density.

OBJECTIVE

Examine the effects of state breast density notification laws on use of supplemental breast imaging and breast biopsies.

DESIGN

Difference-in-differences analysis of supplemental imaging and biopsies before and after notification laws in 12 states enacting breast density notification laws from 2009 to 2014 and 12 matched control states. Supplemental imaging/biopsy within 6 months following an index mammogram were evaluated during four time periods related to legislation: (1) 6 months before, (2) 0-6 months after, (3) 6-12 months after, and (4) 12-18 months after.

PARTICIPANTS

Women ages 40-64 years receiving an initial mammogram in a state that passed a breast density notification law or a control state.

INTERVENTION

Mandatory breast density notification following an index mammogram.

MAIN MEASURES

Use of breast biopsies and supplemental breast imaging (breast ultrasound, tomosynthesis, magnetic resonance imaging, scintimammography, and thermography), overall and by specific test.

KEY RESULTS

Supplemental breast imaging and biopsy increased modestly in states with notification laws and changed minimally in control states. Adjusted rates of supplemental imaging and biopsy within 6 months of mammography before legislation were 8.5% and 3.1%, respectively. Compared with pre-legislation in intervention and control states, legislation was associated with adjusted difference-in-differences estimates of + 1.3% (p < 0.0001) and + 0.4% (p < 0.0001) for supplemental imaging and biopsies, respectively, in the 6-12 months after the law and difference-in-differences estimates of + 3.3% (p < 0.0001) and + 0.8% (p < 0.0001) for supplemental imaging and biopsies, respectively, 12-18 months after the law.

CONCLUSIONS

As breast density notification laws are considered, policymakers and clinicians should expect increases in breast imaging/biopsies. Additional research is needed on these laws' effects on cost and patient outcomes.

Breast density implications and supplemental screening

Digital breast tomosynthesis (DBT) has been widely implemented in place of 2D mammography, although it is less effective in women with extremely dense breasts. Breast ultrasound detects additional early-stage, invasive breast cancers when combined with mammography; however, its relevant limitations, including the shortage of trained operators, operator dependence and small field of view, have limited its widespread implementation. Automated breast sonography (ABS) is a promising technique but the time to interpret and false-positive rates need to be improved. Supplemental screening with contrast-enhanced magnetic resonance imaging (MRI) in high-risk women reduces late-stage disease; abbreviated MRI protocols may reduce cost and increase accessibility to women of average risk with dense breasts. Contrast-enhanced digital mammography (CEDM) and molecular breast imaging improve cancer detection but require further validation for screening and direct biopsy guidance should be implemented for any screening modality. This article reviews the status of screening women with dense breasts. KEY POINTS: • The sensitivity of mammography is reduced in women with dense breasts. Supplemental screening with US detects early-stage, invasive breast cancers. • Tomosynthesis reduces recall rate and increases cancer detection rate but is less effective in women with extremely dense breasts. • Screening MRI improves early diagnosis of breast cancer more than ultrasound and is currently recommended for women at high risk. Risk assessment is needed, to include breast density, to ascertain who should start early annual MRI screening.

Attributes, Performance, and Gaps in Current & Emerging Breast Cancer Screening Technologies

Background:

Early detection of breast cancer, combined with effective treatment, can reduce mortality. Millions of women are diagnosed with breast cancer and many die every year globally. Numerous early detection screening tests have been employed. A wide range of current breast cancer screening methods are reviewed based on a series of searchers focused on clinical testing and performance. </P><P> Discussion: The key factors evaluated centre around the trade-offs between accuracy (sensitivity and specificity), operator dependence of results, invasiveness, comfort, time required, and cost. All of these factors affect the quality of the screen, access/eligibility, and/or compliance to screening programs by eligible women. This survey article provides an overview of the working principles, benefits, limitations, performance, and cost of current breast cancer detection techniques. It is based on an extensive literature review focusing on published works reporting the main performance, cost, and comfort/compliance metrics considered.

Conclusion:

Due to limitations and drawbacks of existing breast cancer screening methods there is a need for better screening methods. Emerging, non-invasive methods offer promise to mitigate the issues particularly around comfort/pain and radiation dose, which would improve compliance and enable all ages to be screened regularly. However, these methods must still undergo significant validation testing to prove they can provide realistic screening alternatives to the current accepted standards.

Relationship between Background Parenchymal Enhancement on High-risk Screening MRI and Future Breast Cancer Risk

RATIONALE AND OBJECTIVES

To determine if background parenchymal enhancement (BPE) on screening breast magnetic resonance imaging (MRI) in high-risk women correlates with future cancer.

MATERIALS AND METHODS

All screening breast MRIs (n = 1039) in high-risk women at our institution from August 1, 2004, to July 30, 2013, were identified. Sixty-one patients who subsequently developed breast cancer were matched 1:2 by age and high-risk indication with patients who did not develop breast cancer (n = 122). Five fellowship-trained breast radiologists independently recorded the BPE. The median reader BPE for each case was calculated and compared between the cancer and control cohorts.

RESULTS

Cancer cohort patients were high-risk because of a history of radiation therapy (10%, 6 of 61), high-risk lesion (18%, 11 of 61), or breast cancer (30%, 18 of 61); BRCA mutation (18%, 11 of 61); or family history (25%, 15 of 61). Subsequent malignancies were invasive ductal carcinoma (64%, 39 of 61), ductal carcinoma in situ (30%, 18 of 61) and invasive lobular carcinoma (7%, 4of 61). BPE was significantly higher in the cancer cohort than in the control cohort (P = 0.01). Women with mild, moderate, or marked BPE were 2.5 times more likely to develop breast cancer than women with minimal BPE (odds ratio = 2.5, 95% confidence interval: 1.3-4.8, P = .005). There was fair interreader agreement (κ = 0.39).

CONCLUSIONS

High-risk women with greater than minimal BPE at screening MRI have increased risk of future breast cancer.

Reliability of automated versus handheld breast ultrasound examinations of suspicious breast masses

PURPOSE

The purpose of this study was to assess the reliability of automated breast ultrasound (ABUS) examinations of suspicious breast masses in comparison to handheld breast ultrasound (HHUS) with regard to Breast Imaging Reporting and Data System (BI-RADS) category assessment, and to investigate the factors affecting discrepancies in categorization.

METHODS

A total of 135 masses that were assessed as BI-RADS categories 4 and 5 on ABUS that underwent ultrasound (US)-guided core needle biopsy from May 2017 to December 2017 were included in this study. The BI-RADS categories were re-assessed using HHUS. Agreement of the BI-RADS categories was evaluated using kappa statistics, and the positive predictive value of each examination was calculated. Logistic regression analysis was performed to identify the mammography and US findings associated with discrepancies in the BI-RADS categorization.

RESULTS

The overall agreement between ABUS and HHUS in all cases was good (79.3%, kappa=0.61, P<0.001). Logistic regression analysis revealed that accompanying suspicious microcalcifications on mammography (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.83 to 11.71; P=0.001) and an irregular shape on US (OR, 5.59; 95% CI, 1.43 to 21.83; P=0.013) were associated with discrepancies in the BI-RADS categorization.

CONCLUSION

The agreement between ABUS and HHUS examinations in the BI-RADS categorization of suspicious breast masses was good. The presence of suspicious microcalcifications on mammography and an irregular shape on US were factors associated with ABUS yielding a lower level of suspicion than HHUS in terms of the BI-RADS category assessment.

Between-Race Differences in Supplemental Breast Cancer Screening Before and After Breast Density Notification Law

Guidelines recommend supplemental breast cancer screening for women at increased breast cancer risk; however, the passage of breast density notification laws may lead to supplemental screening that is incongruent with women's risk. We examined supplemental screening (ie, MRI, ultrasound, or tomosynthesis within 6 months of screening mammogram) among a sample of 2,764 African American (AA) and 691 European American (EA) women with negative or benign screening mammograms for whom we had data from both before and after implementation of breast density notification laws in the state of Michigan. Results indicated a 5-fold increase (from 0.14% to 0.7% of women) in supplemental screening among screen-negative women after passage of the law, driven in large part by an increase in supplemental screening among AA women. Breast density was more predictive of supplemental screening and had a marginally greater explanatory role in between-race differences in supplemental screening after passage of the law. Subgroup analyses (n = 250) indicated that whereas 5-year breast cancer risk was positively associated with supplemental screening before the law and negatively associated after the law for EA women, 5-year risk was not associated with supplemental screening either before or after passage of the law for AA women. Our findings suggest that whereas passage of the breast density notification laws may have motivated supplemental screening among AA women in particular, it lessened the consideration of breast cancer risk in supplemental screening decision making.

Can Biannual Ultrasound Surveillance Detect Smaller Second Cancers or Detect Cancers Earlier in Patients with Breast Cancer History?

The aim of the work described here was to evaluate whether surveillance with biannual ultrasound (US) plus annual mammography (biannual group) for women with a history of breast cancer surgery results in earlier detection or in the detection of smaller second cancers than annual US plus mammography (annual group). Additionally, we compared the prevalence of distant metastases or palpable second cancers between the biannual and annual groups. The institutional review board of our institution approved this retrospective study, and patient consent was waived. Between January 2011 and December 2012, we retrospectively reviewed the clinical and imaging follow-up of 3023 patients with mammographic and US surveillance after breast cancer surgery to assess second cancers detected by local surveillance (locoregional recurrence, contralateral breast cancer or distant metastasis). The biannual and annual groups were divided with respect to the mean surveillance interval and compared with respect to clinicopathologic findings. Multivariable logistic regression with propensity score methods was used to examine the effect of the type of surveillance on outcomes. As for the size of the second cancer, no difference was seen between the biannual and annual groups (12.8 ± 6.6 mm vs. 14.1 ± 7.1 mm, p = 0.461); neither was there a significant difference between the groups in the presence of symptoms at the time of diagnosis of the second cancer (17.0% [8/47] vs. 10% [2/20], p = 0.711). Regardless of detection by local surveillance, the prevalence of distant metastases did not differ between the two groups (1.1% [27/2370] vs. 1.0% [7/653], p = 0.88) on univariate or multivariate analysis. The results of our retrospective study indicate that second cancers detected by biannual US surveillance in patients with a history of breast cancer surgery are not smaller and do not occur earlier than those detected by annual US surveillance. However, a randomized controlled study is required to verify these results before they can be generalized to clinical practice.

Addition of ultrasound to mammography in the case of dense breast tissue: systematic review and meta-analysis

BACKGROUND

Mammography is less effective in detecting cancer in dense than in fatty breasts.

METHODS

We undertook a systematic search in PubMed to identify studies on women with dense breasts who underwent screening with mammography supplemented with ultrasound. A meta-analysis was undertaken on the proportion of cancers detected only by ultrasound, out of all screen-detected cancers, and the proportion of women with negative mammography who were referred for assessment following ultrasound screening.

RESULTS

Twenty-nine studies satisfied our inclusion criteria. The proportion of total cancers detected only by ultrasound was 0.29 (95% CI: 0.27-0.31), consistent with an approximately 40% increase in the detection of cancers compared to mammography. In the studied populations, this translated into an additional 3.8 (95% CI: 3.4-4.2) screen-detected cases per 1000 mammography-negative women. About 13% (32/248) of cancers were in situ from 17 studies with information on this subgroup. Ultrasound approximately doubled the referral for assessment in three studies with these data.

CONCLUSIONS

Studies have consistently shown an increased detection of breast cancer by supplementary ultrasound screening. An inclusion of supplementary ultrasound into routine screening will need to consider the availability of ultrasound and diagnostic assessment capacities.

Addressing Potential Health Disparities in the Adoption of Advanced Breast Imaging Technologies

With the advent of new screening technologies, including digital breast tomosynthesis, screening ultrasound, and breast magnetic resonance imaging, there is growing concern that existing disparities among traditionally underserved populations will worsen. These newer screening modalities purport improved cancer detection over mammography alone but are not offered at all screening facilities and often require a larger co-pay or out-of-pocket expense. Thus, the potential for worsening disparities with regard to access and appropriate utilization of supplemental screening technologies exists. Currently, there is a dearth of literature on the topic of health disparities related to access and the use of supplemental breast cancer screening and their impact on outcomes. Identifying and addressing explanatory factors for persistent and potentially worsening disparities remain a central focus of efforts to improve equity in breast cancer care. Therefore, this paper provides an overview of factors that may contribute to present and future disparities in breast cancer screening and outcomes, and explores specific relevant topics requiring greater research efforts as more personalized, multimodality breast cancer screening approaches are adopted into clinical practice.

Underutilization of Supplemental Magnetic Resonance Imaging Screening Among Patients at High Breast Cancer Risk

BACKGROUND

Women at high lifetime breast cancer risk may benefit from supplemental breast magnetic resonance imaging (MRI) screening, in addition to routine mammography screening for earlier cancer detection.

MATERIALS AND METHODS

We performed a cross-sectional study of 422,406 women undergoing routine mammography screening across 86 Breast Cancer Surveillance Consortium (BCSC) facilities during calendar year 2012. We determined availability and use of on-site screening breast MRI services based on woman-level characteristics, including >20% lifetime absolute risk using the National Cancer Institute risk assessment tool. Multivariate analyses were performed to determine sociodemographic characteristics associated with on-site screening MRI use.

RESULTS

Overall, 43.9% (2403/5468) of women at high lifetime risk attended a facility with on-site breast MRI screening availability. However, only 6.6% (158/2403) of high-risk women obtained breast MRI screening within a 2-year window of their screening mammogram. Patient factors associated with on-site MRI screening use included younger (<40 years) age (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.34-4.21), family history (OR = 1.72, 95% CI: 1.13-2.63), prior breast biopsy (OR = 2.09, 95% CI: 1.22-3.58), and postsecondary education (OR = 2.22, 95% CI: 1.04-4.74).

CONCLUSIONS

While nearly half of women at high lifetime breast cancer risk undergo routine screening mammography at a facility with on-site breast MRI availability, supplemental breast MRI remains widely underutilized among those who may benefit from earlier cancer detection. Future studies should evaluate whether other enabling factors such as formal risk assessment and patient awareness of high lifetime breast cancer risk can mitigate the underutilization of supplemental screening breast MRI.

Is there an extraclinical value of automated breast volume scanner compared with hand-held ultrasound?: A pilot study

The aim of this study was to investigate the extraclinical value of automated breast volume scanning (ABVS) in the diagnosis of breast tumor compare to hand-handle ultrasound (HHUS).One hundred twenty-four patients with breast tumor were performed HHUS and ABVS before operation. The research focused on whether there were newly found tumors or new findings on the coronal planes by using ABVS compared with HHUS. Then, the classification adjustments of breast imaging reporting and data system (BI-RADS) were made according to new findings on the coronal planes by using ABVS.There are totally 166 breast tumors found in 124 patients by HHUS, while 8 more were observed by ABVS, 4 of which were malignant and the rest were benign. The sensitivity and specificity of ABVS coronal plane findings were 37.0% and 92.5%, respectively. The area under receiver operating characteristic curve was 0.89 before the corrected classification versus 0.93 after the corrected classification, there were no significant differences (P > .05).There was no significant extraclinical value in differentiating diagnosis of malignant tumors and benign breast tumors by ABVS comparing to HHUS. However, those minimal lesions missed diagnosis could be found by ABVS with continuously automatic scanning.

The performance of 3D ABUS versus HHUS in the visualisation and BI-RADS characterisation of breast lesions in a large cohort of 1,886 women

OBJECTIVES

This study aimed to evaluate automated breast ultrasound (ABUS) compared to hand-held traditional ultrasound (HHUS) in the visualisation and BIRADS characterisation of breast lesions.

MATERIALS AND METHODS

From January 2016 to January 2017, 1,886 women with breast density category C or D (aged 48.6±10.8 years) were recruited. All participants underwent ABUS and HHUS examination; a subcohort of 1,665 women also underwent a mammography.

RESULTS

The overall agreement between HHUS and ABUS was 99.8 %; kappa=0.994, p<0.0001. Two cases were graded as BI-RADS 1 in HHUS, but were graded as BIRADS 4 in ABUS; biopsy revealed a radial scar. Three carcinomas were graded as BI-RADS 2 in mammography but BI-RADS 4 in ABUS; two additional carcinomas were graded as BI-RADS 2 in mammography but BI-RADS 5 in ABUS. Two carcinomas, appearing as a well-circumscribed mass or developing asymmetry in mammography, were graded as BI-RADS 4 in mammography but BI-RADS 5 in ABUS.

CONCLUSIONS

ABUS could be successfully used in the visualisation and characterisation of breast lesions. ABUS seemed to outperform HHUS in the detection of architectural distortion on the coronal plane and can supplement mammography in the detection of non-calcified carcinomas in women with dense breasts.

KEY POINTS

• The new generation of ABUS yields comparable results to HHUS. • ABUS seems superior to HHUS in detecting architectural distortions. • In dense breasts, supplemental ABUS to mammography detects additional cancers.

Automated Breast Density Computation in Digital Mammography and Digital Breast Tomosynthesis: Influence on Mean Glandular Dose and BIRADS Density Categorization

RATIONALE AND OBJECTIVES

The study aimed to compare the breast density estimates from two algorithms on full-field digital mammography (FFDM) and digital breast tomosynthesis (DBT) and to analyze the clinical implications.

MATERIALS AND METHODS

We selected 561 FFDM and DBT examinations from patients without breast pathologies. Two versions of a commercial software (Quantra 2D and Quantra 3D) calculated the volumetric breast density automatically in FFDM and DBT, respectively. Other parameters such as area breast density and total breast volume were evaluated. We compared the results from both algorithms using the Mann-Whitney U non-parametric test and the Spearman's rank coefficient for data correlation analysis. Mean glandular dose (MGD) was calculated following the methodology proposed by Dance et al.

RESULTS

Measurements with both algorithms are well correlated (r ≥ 0.77). However, there are statistically significant differences between the medians (P < 0.05) of most parameters. The volumetric and area breast density median values from FFDM are, respectively, 8% and 77% higher than DBT estimations. Both algorithms classify 35% and 55% of breasts into BIRADS (Breast Imaging-Reporting and Data System) b and c categories, respectively. There are no significant differences between the MGD calculated using the breast density from each algorithm. DBT delivers higher MGD than FFDM, with a lower difference (5%) for breasts in the BIRADS d category. MGD is, on average, 6% higher than values obtained with the breast glandularity proposed by Dance et al.

CONCLUSIONS

Breast density measurements from both algorithms lead to equivalent BIRADS classification and MGD values, hence showing no difference in clinical outcomes. The median MGD values of FFDM and DBT examinations are similar for dense breasts (BIRADS d category).

Breast magnetic resonance imaging: are those who need it getting it?

BACKGROUND

Indications for breast magnetic resonance imaging (mri), a very sensitive but less-specific tool for breast investigation, remain controversial, and accessibility is limited. The purposes of our study were to determine the proportion of breast mri exams performed for various clinical indications, to assess the wait times for breast mri, and to create a list of evidence-based indications for breast mri.

METHODS

The indications for breast mri exams performed in September 2013 at our academic centre were audited. A multidisciplinary meeting held in May 2014 established a list of evidence-based indications for breast mri, after which, in September 2014 and 2015, breast mri exams were re-audited for clinical indications, and pending requests were calculated.

RESULTS

In September 2013, surveillance of women with a prior diagnosis of breast cancer represented 21% of breast mri exams (24 of 113), with preoperative staging representing 18% of exams (20 of 113) and high-risk screening representing 12% (13 of 113). Of pending mri requests, 230 were within the recommended delay period, and 457 exceeded the recommended delay. After elaboration of evidence-based guidelines, repeat audits in September 2014 and September 2015 showed that mri performed for women with a prior breast cancer diagnosis represented 23% (33 of 141) and 7% (10 of 143) of exams respectively, with preoperative staging having declined to 9% (13 of 141) and 11% (16 of 143) of exams, and high-risk screening having increased to 36% (51 of 141) and 46% (66 of 143) of exams. Overall, wait times were improved for all breast mri indications.

CONCLUSIONS

Through multidisciplinary discussion, we actualized a list of breast mri indications, prioritized requests more adequately, and improved wait times.

A Noninvasive Blood-based Combinatorial Proteomic Biomarker Assay to Detect Breast Cancer in Women Under the Age of 50 Years

BACKGROUND

Despite significant advances in breast imaging, the ability to detect breast cancer (BC) remains a challenge. To address the unmet needs of the current BC detection paradigm, 2 prospective clinical trials were conducted to develop a blood-based combinatorial proteomic biomarker assay (Videssa Breast) to accurately detect BC and reduce false positives (FPs) from suspicious imaging findings.

PATIENTS AND METHODS

Provista-001 and Provista-002 (cohort one) enrolled Breast Imaging Reporting and Data System 3 or 4 women aged under 50 years. Serum was evaluated for 11 serum protein biomarkers and 33 tumor-associated autoantibodies. Individual biomarker expression, demographics, and clinical characteristics data from Provista-001 were combined to develop a logistic regression model to detect BC. The performance was tested using Provista-002 cohort one (validation set).

RESULTS

The training model had a sensitivity and specificity of 92.3% and 85.3% (BC prevalence, 7.7%), respectively. In the validation set (BC prevalence, 2.9%), the sensitivity and specificity were 66.7% and 81.5%, respectively. The negative predictive value was high in both sets (99.3% and 98.8%, respectively). Videssa Breast performance in the combined training and validation set was 99.1% negative predictive value, 87.5% sensitivity, 83.8% specificity, and 25.2% positive predictive value (BC prevalence, 5.87%). Overall, imaging resulted in 341 participants receiving follow-up procedures to detect 30 cancers (90.6% FP rate). Videssa Breast would have recommended 111 participants for follow-up, a 67% reduction in FPs (P < .00001).

CONCLUSIONS

Videssa Breast can effectively detect BC when used in conjunction with imaging and can substantially reduce unnecessary medical procedures, as well as provide assurance to women that they likely do not have BC.

The Relationship Between Breast Cancer and Risk Factors: A Single-Center Study

OBJECTIVE

To determine the relationship between breast cancer and known risk factors in patients who had mammography (MG) for breast cancer screening or ultrasonography and/or MG for diagnostic purposes.

MATERIALS AND METHODS

In the period of January-December, 2011, a questionnaire composed of 17 questions was applied to 2862 female patients and MG and/or US examination was performed afterwards. Chi-square and Kruskal-Wallis tests were used for statistical analysis.

RESULTS

The mean age was 51.05±8.98, age at menarche was 13.0±1.6 and age at menopause was 47±5.2. The first pregnancy was at 20±4.6. Out of 2862 cases, 242 had breast cancer diagnosis and 32 were newly diagnosed. There was no correlation between menarche age, age at menopause or first pregnancy and breast cancer. There was no relationship between breast cancer risk and hormone replacement therapy or oral contraceptive use. In patients with the diagnosis of breast cancer (242 cases), 61 had (25%) a positive family history. There was a significant correlation between the presence of a positive family history and having breast cancer (p=0.003).

CONCLUSION

The presence of breast cancer in the family has the strongest relationship among all risk factors. It is important to have regular followup of these patients and to raise the awareness of patients.

Screening Breast MRI Outcomes in Routine Clinical Practice: Comparison to BI-RADS Benchmarks

RATIONALE AND OBJECTIVES

The BI-RADS Atlas 5th Edition includes screening breast magnetic resonance imaging (MRI) outcome benchmarks. However, the metrics are from expert practices and clinical trials of women with hereditary breast cancer predispositions, and it is unknown if they are appropriate for routine practice. We evaluated screening breast MRI audit outcomes in routine practice across a spectrum of elevated risk patients.

MATERIALS AND METHODS

This Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all consecutive screening breast MRI examinations from July 1, 2010 to June 30, 2013. Examination indications were categorized as gene mutation carrier (GMC), personal history (PH) breast cancer, family history (FH) breast cancer, chest radiation, and atypia/lobular carcinoma in situ (LCIS). Outcomes were determined by pathology and/or ≥12 months clinical and/or imaging follow-up. We calculated abnormal interpretation rate (AIR), cancer detection rate (CDR), positive predictive value of recommendation for tissue diagnosis (PPV2) and biopsy performed (PPV3), and median size and percentage of node-negative invasive cancers.

RESULTS

Eight hundred and sixty examinations were performed in 566 patients with a mean age of 47 years. Indications were 367 of 860 (42.7%) FH, 365 of 860 (42.4%) PH, 106 of 860 (12.3%) GMC, 14 of 860 (1.6%) chest radiation, and 8 of 22 (0.9%) atypia/LCIS. The AIR was 134 of 860 (15.6%). Nineteen cancers were identified (13 invasive, 4 DCIS, two lymph nodes), resulting in CDR of 19 of 860 (22.1 per 1000), PPV2 of 19 of 88 (21.6%), and PPV3 of 19 of 80 (23.8%). Of 13 invasive breast cancers, median size was 10 mm, and 8 of 13 were node negative (61.5%).

CONCLUSIONS

Performance outcomes of screening breast MRI in routine clinical practice across a spectrum of elevated risk patients met the American College of Radiology Breast Imaging Reporting and Data System benchmarks, supporting broad application of these metrics. The indication of a personal history of treated breast cancer accounted for a large proportion (42%) of our screening examinations, with breast MRI performance in this population at least comparable to that of other screening indications.

Mammographic Breast Density and Breast Cancer Risk: Implications of the Breast Density Legislation for Health Care Practitioners

Breast density has emerged as a critical phenotypic marker of increased breast cancer risk. The breast density legislation, passed in multiple states, requires patient notification of the implications of the breast density on breast cancer risk and screening. Supplemental screening may be suggested in the state regulation; however, there are limited data to guide conversations with patients. This article will review the current state of supplemental screening in women with dense breasts and discuss theories of the mechanism of action. Guidance is provided to assist in shared decision making and appropriate patient counseling.