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Barlow WE, Beaber EF, Geller BM, Kamineni A, Zheng Y, Haas JS, Chao CR, Rutter CM, Zauber AG, Sprague BL, Halm EA, Weaver DL, Chubak J, Doria-Rose VP, Kobrin S, Onega T, Quinn VP, Schapira MM, Tosteson ANA, Corley DA, Skinner CS, Schnall MD, Armstrong K, Wheeler CM, Silverberg MJ, Balasubramanian BA, Doubeni CA, McLerran D, Tiro JA. Evaluating Screening Participation, Follow-up, and Outcomes for Breast, Cervical, and Colorectal Cancer in the PROSPR Consortium. J Natl Cancer Inst 2020; 112:238-246. [PMID: 31292633 DOI: 10.1093/jnci/djz137] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/11/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cancer screening is a complex process encompassing risk assessment, the initial screening examination, diagnostic evaluation, and treatment of cancer precursors or early cancers. Metrics that enable comparisons across different screening targets are needed. We present population-based screening metrics for breast, cervical, and colorectal cancers for nine sites participating in the Population-based Research Optimizing Screening through Personalized Regimens consortium. METHODS We describe how selected metrics map to a trans-organ conceptual model of the screening process. For each cancer type, we calculated calendar year 2013 metrics for the screen-eligible target population (breast: ages 40-74 years; cervical: ages 21-64 years; colorectal: ages 50-75 years). Metrics for screening participation, timely diagnostic evaluation, and diagnosed cancers in the screened and total populations are presented for the total eligible population and stratified by age group and cancer type. RESULTS The overall screening-eligible populations in 2013 were 305 568 participants for breast, 3 160 128 for cervical, and 2 363 922 for colorectal cancer screening. Being up-to-date for testing was common for all three cancer types: breast (63.5%), cervical (84.6%), and colorectal (77.5%). The percentage of abnormal screens ranged from 10.7% for breast, 4.4% for cervical, and 4.5% for colorectal cancer screening. Abnormal breast screens were followed up diagnostically in almost all (96.8%) cases, and cervical and colorectal were similar (76.2% and 76.3%, respectively). Cancer rates per 1000 screens were 5.66, 0.17, and 1.46 for breast, cervical, and colorectal cancer, respectively. CONCLUSIONS Comprehensive assessment of metrics by the Population-based Research Optimizing Screening through Personalized Regimens consortium enabled systematic identification of screening process steps in need of improvement. We encourage widespread use of common metrics to allow interventions to be tested across cancer types and health-care settings.
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Affiliation(s)
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Berta M Geller
- Departments of Family Medicine, and the University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Dana Farber, Harvard Cancer Institute, Harvard School of Public Health, Boston, MA
| | - Chun R Chao
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian L Sprague
- Departments of Surgery and Radiology, University of Vermont, Burlington, VT
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Donald L Weaver
- Department of Pathology and the UVM Cancer Center, University of Vermont, Burlington, VT
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - V Paul Doria-Rose
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Sarah Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Tracy Onega
- Departments of Biomedical Data Science, Epidemiology, and the Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Marilyn M Schapira
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and CMC VA Medical Center, Philadelphia, PA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mitchell D Schnall
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Katrina Armstrong
- General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA
| | - Cosette M Wheeler
- Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.,University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | | | - Bijal A Balasubramanian
- Simmons Comprehensive Cancer Center, Dallas, TX.,UTHealth School of Public Health, Dallas, TX
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Dale McLerran
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jasmin A Tiro
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
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2
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Sprague BL, Vacek PM, Herschorn SD, James TA, Geller BM, Trentham-Dietz A, Stein JL, Weaver DL. Time-varying risks of second events following a DCIS diagnosis in the population-based Vermont DCIS cohort. Breast Cancer Res Treat 2018; 174:227-235. [PMID: 30448897 DOI: 10.1007/s10549-018-5048-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Long-term disease-free survival patterns following surgical, radiation, and endocrine therapy treatments for ductal carcinoma in situ (DCIS) are not well characterized in general US practice. METHODS We identified 1252 women diagnosed with DCIS in Vermont during 1994-2012 using data from the Vermont Breast Cancer Surveillance System, a statewide registry of breast imaging and pathology records. Poisson regression and Cox regression with time-varying hazards were used to evaluate disease-free survival among self-selected treatment groups. RESULTS With 7.8 years median follow-up, 192 cases experienced a second breast cancer diagnosis. For women treated with breast-conserving surgery (BCS) alone, the annual rate of second events decreased from 3.1% (95% CI 2.2-4.2%) during follow-up years 1-5 to 1.7% (95% CI 0.7-3.5%) after 10 years. In contrast, the annual rate of second events among women treated with BCS plus adjuvant radiation therapy increased from 1.8% (95% CI 1.1-2.6%) during years 1-5 to 2.8% (95% CI 1.6-4.7%) after 10 years (P < 0.05 for difference in trend compared to BCS alone). Annual rates of second events also increased over time among women treated with BCS plus adjuvant radiation and endocrine therapy (P = 0.01 for difference in trend compared to BCS alone). The rate of contralateral events increased after 10 years for all groups with adjuvant treatments. The rate of second events did not vary over time among women who underwent ipsilateral mastectomy (P = 0.62). CONCLUSIONS Long-term risk of a second event after DCIS varies over time in a manner dependent on initial treatment.
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Affiliation(s)
- Brian L Sprague
- Department of Surgery, University of Vermont, 1 S. Prospect St, UHC Room 4425, Burlington, VT, 05401, USA. .,Department of Radiology, University of Vermont, Burlington, VT, USA. .,University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA.
| | - Pamela M Vacek
- University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA.,Medical Biostatistics Unit, University of Vermont, Burlington, VT, USA
| | - Sally D Herschorn
- Department of Radiology, University of Vermont, Burlington, VT, USA.,University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA
| | - Ted A James
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Amy Trentham-Dietz
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Janet L Stein
- University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA.,Department of Biochemistry, University of Vermont, Burlington, VT, USA
| | - Donald L Weaver
- University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA.,Department of Pathology, University of Vermont, Burlington, VT, USA
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3
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Onega T, Weaver DL, Frederick PD, Allison KH, Tosteson ANA, Carney PA, Geller BM, Longton GM, Nelson HD, Oster NV, Pepe MS, Elmore JG. The diagnostic challenge of low-grade ductal carcinoma in situ. Eur J Cancer 2017; 80:39-47. [PMID: 28535496 DOI: 10.1016/j.ejca.2017.04.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diagnostic agreement among pathologists is 84% for ductal carcinoma in situ (DCIS). Studies of interpretive variation according to grade are limited. METHODS A national sample of 115 pathologists interpreted 240 breast pathology test set cases in the Breast Pathology Study and their interpretations were compared to expert consensus interpretations. We assessed agreement of pathologists' interpretations with a consensus reference diagnosis of DCIS dichotomised into low- and high-grade lesions. Generalised estimating equations were used in logistic regression models of rates of under- and over-interpretation of DCIS by grade. RESULTS We evaluated 2097 independent interpretations of DCIS (512 low-grade DCIS and 1585 high-grade DCIS). Agreement with reference diagnoses was 46% (95% confidence interval [CI] 42-51) for low-grade DCIS and 83% (95% CI 81-86) for high-grade DCIS. The proportion of reference low-grade DCIS interpretations over-interpreted by pathologists (i.e. categorised as either high-grade DCIS or invasive cancer) was 23% (95% CI 19-28); 30% (95% CI 26-34) were interpreted as a lower diagnostic category (atypia or benign proliferative). Reference high-grade DCIS was under-interpreted in 14% (95% CI 12-16) of observations and only over-interpreted 3% (95% CI 2-4). CONCLUSION Grade is a major factor when examining pathologists' variability in diagnosing DCIS, with much lower agreement for low-grade DCIS cases compared to high-grade. These findings support the hypothesis that low-grade DCIS poses a greater interpretive challenge than high-grade DCIS, which should be considered when developing DCIS management strategies.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, VT, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Anna N A Tosteson
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT 05401, USA
| | - Gary M Longton
- Department of Biostatistics, University of Washington, Seattle, WA 98101, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Department of Medical Informatics and Clinical Epidemiology and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Natalia V Oster
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret S Pepe
- Department of Biostatistics, University of Washington, Seattle, WA 98101, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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4
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Geller BM, Nelson HD, Weaver DL, Frederick PD, Allison KH, Onega T, Carney PA, Tosteson ANA, Elmore JG. Characteristics associated with requests by pathologists for second opinions on breast biopsies. J Clin Pathol 2017; 70:947-953. [PMID: 28465449 DOI: 10.1136/jclinpath-2016-204231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/22/2017] [Accepted: 03/29/2017] [Indexed: 01/14/2023]
Abstract
AIMS Second opinions in pathology improve patient safety by reducing diagnostic errors, leading to more appropriate clinical treatment decisions. Little objective data are available regarding the factors triggering a request for second opinion despite second opinion consultations being part of the diagnostic system of pathology. Therefore we sought to assess breast biopsy cases and interpreting pathologists characteristics associated with second opinion requests. METHODS Collected pathologist surveys and their interpretations of 60 test set cases were used to explore the relationships between case characteristics, pathologist characteristics and case perceptions, and requests for second opinions. Data were evaluated by logistic regression and generalised estimating equations. RESULTS 115 pathologists provided 6900 assessments; pathologists requested second opinions on 70% (4827/6900) of their assessments 36% (1731/4827) of these would not have been required by policy. All associations between case characteristics and requesting second opinions were statistically significant, including diagnostic category, breast density, biopsy type, and number of diagnoses noted per case. Exclusive of institutional policies, pathologists wanted second opinions most frequently for atypia (66%) and least frequently for invasive cancer (20%). Second opinion rates were higher when the pathologist had lower assessment confidence, in cases with higher perceived difficulty, and cases with borderline diagnoses. CONCLUSIONS Pathologists request second opinions for challenging cases, particularly those with atypia, high breast density, core needle biopsies, or many co-existing diagnoses. Further studies should evaluate whether the case characteristics identified in this study could be used as clinical criteria to prompt system-level strategies for mandating second opinions.
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Affiliation(s)
- Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, Vermont, USA
| | - Heidi D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University; and Providence Cancer Center, Portland, Oregon, USA
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, Vermont, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Tracy Onega
- Departments of Biomedical Data Science and Epidemiology, Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, New Hampshire, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Anna N A Tosteson
- Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, New Hampshire, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, Washington, USA
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5
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Elmore JG, Longton GM, Pepe MS, Carney PA, Nelson HD, Allison KH, Geller BM, Onega T, Tosteson ANA, Mercan E, Shapiro LG, Brunyé TT, Morgan TR, Weaver DL. A Randomized Study Comparing Digital Imaging to Traditional Glass Slide Microscopy for Breast Biopsy and Cancer Diagnosis. J Pathol Inform 2017; 8:12. [PMID: 28382226 PMCID: PMC5364740 DOI: 10.4103/2153-3539.201920] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/18/2017] [Indexed: 01/19/2023] Open
Abstract
Background: Digital whole slide imaging may be useful for obtaining second opinions and is used in many countries. However, the U.S. Food and Drug Administration requires verification studies. Methods: Pathologists were randomized to interpret one of four sets of breast biopsy cases during two phases, separated by ≥9 months, using glass slides or digital format (sixty cases per set, one slide per case, n = 240 cases). Accuracy was assessed by comparing interpretations to a consensus reference standard. Intraobserver reproducibility was assessed by comparing the agreement of interpretations on the same cases between two phases. Estimated probabilities of confirmation by a reference panel (i.e., predictive values) were obtained by incorporating data on the population prevalence of diagnoses. Results: Sixty-five percent of responding pathologists were eligible, and 252 consented to randomization; 208 completed Phase I (115 glass, 93 digital); and 172 completed Phase II (86 glass, 86 digital). Accuracy was slightly higher using glass compared to digital format and varied by category: invasive carcinoma, 96% versus 93% (P = 0.04); ductal carcinoma in situ (DCIS), 84% versus 79% (P < 0.01); atypia, 48% versus 43% (P = 0.08); and benign without atypia, 87% versus 82% (P < 0.01). There was a small decrease in intraobserver agreement when the format changed compared to when glass slides were used in both phases (P = 0.08). Predictive values for confirmation by a reference panel using glass versus digital were: invasive carcinoma, 98% and 97% (not significant [NS]); DCIS, 70% and 57% (P = 0.007); atypia, 38% and 28% (P = 0.002); and benign without atypia, 97% and 96% (NS). Conclusions: In this large randomized study, digital format interpretations were similar to glass slide interpretations of benign and invasive cancer cases. However, cases in the middle of the spectrum, where more inherent variability exists, may be more problematic in digital format. Future studies evaluating the effect these findings exert on clinical practice and patient outcomes are required.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Gary M Longton
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Margaret S Pepe
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; Department of Biostatistics, University of Washington School of Public Health, Seattle, WA 98104, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, OR 97239, USA
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239, USA; Providence Cancer Center, Providence Health and Services Oregon, Portland, OR 97213, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT 05405, USA
| | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Ezgi Mercan
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Linda G Shapiro
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Tad T Brunyé
- Department of Psychology, Tufts University, Medford, MA 02155, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT 05405, USA
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6
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Onega T, Reisch LM, Frederick PD, Geller BM, Nelson HD, Lott JP, Radick AC, Elder DE, Barnhill RL, Piepkorn MW, Elmore JG. Use of Digital Whole Slide Imaging in Dermatopathology. J Digit Imaging 2017; 29:243-53. [PMID: 26546178 DOI: 10.1007/s10278-015-9836-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Digital whole slide imaging (WSI) is an emerging technology for pathology interpretation, with specific challenges for dermatopathology, yet little is known about pathologists' practice patterns or perceptions regarding WSI for interpretation of melanocytic lesions. A national sample of pathologists (N = 207) was recruited from 864 invited pathologists from ten US states (CA, CT, HI, IA, KY, LA, NJ, NM, UT, and WA). Pathologists who had interpreted melanocytic lesions in the past year were surveyed in this cross-sectional study. The survey included questions on pathologists' experience, WSI practice patterns and perceptions using a 6-point Likert scale. Agreement was summarized with descriptive statistics to characterize pathologists' use and perceptions of WSI. The majority of participating pathologists were between 40 and 59 years of age (62%) and not affiliated with an academic medical center (71%). Use of WSI was seen more often among dermatopathologists and participants affiliated with an academic medical center. Experience with WSI was reported by 41%, with the most common type of use being for education and testing (CME, board exams, and teaching in general, 71%), and clinical use at tumor boards and conferences (44%). Most respondents (77%) agreed that accurate diagnoses can be made with this technology, and 59% agreed that benefits of WSI outweigh concerns. However, 78% of pathologists reported that digital slides are too slow for routine clinical interpretation. The respondents were equally split as to whether they would like to adopt WSI (49%) or not (51%). The majority of pathologists who interpret melanocytic lesions do not use WSI, but among pathologists who do, use is largely for CME, licensure/board exams, and teaching. Positive perceptions regarding WSI slightly outweigh negative perceptions. Understanding practice patterns with WSI as dissemination advances may facilitate concordance of perceptions with adoption of the technology.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, NH, USA.
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
| | | | | | - Berta M Geller
- Department of Family Medicine, University of Vermont Burlington, Burlington, VT, USA
| | | | | | | | - David E Elder
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris, France
- University of California, Los Angeles, CA, USA
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Dermatopathology Northwest, Bellevue, WA, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, WA, USA
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7
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Jackson SL, Frederick PD, Pepe MS, Nelson HD, Weaver DL, Allison KH, Carney PA, Geller BM, Tosteson ANA, Onega T, Elmore JG. Diagnostic Reproducibility: What Happens When the Same Pathologist Interprets the Same Breast Biopsy Specimen at Two Points in Time? Ann Surg Oncol 2016; 24:1234-1241. [PMID: 27913946 DOI: 10.1245/s10434-016-5695-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgeons may receive a different diagnosis when a breast biopsy is interpreted by a second pathologist. The extent to which diagnostic agreement by the same pathologist varies at two time points is unknown. METHODS Pathologists from eight U.S. states independently interpreted 60 breast specimens, one glass slide per case, on two occasions separated by ≥9 months. Reproducibility was assessed by comparing interpretations between the two time points; associations between reproducibility (intraobserver agreement rates); and characteristics of pathologists and cases were determined and also compared with interobserver agreement of baseline interpretations. RESULTS Sixty-five percent of invited, responding pathologists were eligible and consented; 49 interpreted glass slides in both study phases, resulting in 2940 interpretations. Intraobserver agreement rates between the two phases were 92% [95% confidence interval (CI) 88-95] for invasive breast cancer, 84% (95% CI 81-87) for ductal carcinoma-in-situ, 53% (95% CI 47-59) for atypia, and 84% (95% CI 81-86) for benign without atypia. When comparing all study participants' case interpretations at baseline, interobserver agreement rates were 89% (95% CI 84-92) for invasive cancer, 79% (95% CI 76-81) for ductal carcinoma-in-situ, 43% (95% CI 41-45) for atypia, and 77% (95% CI 74-79) for benign without atypia. CONCLUSIONS Interpretive agreement between two time points by the same individual pathologist was low for atypia and was similar to observed rates of agreement for atypia between different pathologists. Physicians and patients should be aware of the diagnostic challenges associated with a breast biopsy diagnosis of atypia when considering treatment and surveillance decisions.
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Affiliation(s)
- Sara L Jackson
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret S Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, Portland, USA.,Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, USA
| | - Anna N A Tosteson
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Tracy Onega
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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8
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McCarthy AM, Kim JJ, Beaber EF, Zheng Y, Burnett-Hartman A, Chubak J, Ghai NR, McLerran D, Breen N, Conant EF, Geller BM, Green BB, Klabunde CN, Inrig S, Skinner CS, Quinn VP, Haas JS, Schnall M, Rutter CM, Barlow WE, Corley DA, Armstrong K, Doubeni CA. Follow-Up of Abnormal Breast and Colorectal Cancer Screening by Race/Ethnicity. Am J Prev Med 2016; 51:507-12. [PMID: 27132628 PMCID: PMC5030116 DOI: 10.1016/j.amepre.2016.03.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Timely follow-up of abnormal tests is critical to the effectiveness of cancer screening, but may vary by screening test, healthcare system, and sociodemographic group. METHODS Timely follow-up of abnormal mammogram and fecal occult blood testing or fecal immunochemical tests (FOBT/FIT) were compared by race/ethnicity using Population-Based Research Optimizing Screening through Personalized Regimens consortium data. Participants were women with an abnormal mammogram (aged 40-75 years) or FOBT/FIT (aged 50-75 years) in 2010-2012. Analyses were performed in 2015. Timely follow-up was defined as colonoscopy ≤3 months following positive FOBT/FIT; additional imaging or biopsy ≤3 months following Breast Imaging Reporting and Data System Category 0, 4, or 5 mammograms; or ≤9 months following Category 3 mammograms. Logistic regression was used to model receipt of timely follow-up adjusting for study site, age, year, insurance, and income. RESULTS Among 166,602 mammograms, 10.7% were abnormal; among 566,781 FOBT/FITs, 4.3% were abnormal. Nearly 96% of patients with abnormal mammograms received timely follow-up versus 68% with abnormal FOBT/FIT. There was greater variability in receipt of follow-up across healthcare systems for positive FOBT/FIT than for abnormal mammograms. For mammography, black women were less likely than whites to receive timely follow-up (91.8% vs 96.0%, OR=0.71, 95% CI=0.51, 0.97). For FOBT/FIT, Hispanics were more likely than whites to receive timely follow-up than whites (70.0% vs 67.6%, OR=1.12, 95% CI=1.04, 1.21). CONCLUSIONS Timely follow-up among women was more likely for abnormal mammograms than FOBT/FITs, with small variations in follow-up rates by race/ethnicity and larger variation across healthcare systems.
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Affiliation(s)
- Anne Marie McCarthy
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yingye Zheng
- Department of Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Andrea Burnett-Hartman
- Division of Epidemiology, Fred Hutchinson Cancer Research Center, Seattle, Washington; Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | | | - Nirupa R Ghai
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Dale McLerran
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nancy Breen
- Health Systems and Interventions Research Branch, National Cancer Institute, Bethesda, Maryland
| | - Emily F Conant
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, Vermont
| | | | | | - Stephen Inrig
- Department of Health Policy and History of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Health Policy and Management, Mount Saint Mary's University, Los Angeles, California
| | - Celette Sugg Skinner
- Department of Clinical Science and Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Virginia P Quinn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jennifer S Haas
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchell Schnall
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - William E Barlow
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Douglas A Corley
- Department of Gastroenterology, Kaiser Permanente Northern California, Oakland, California
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Carney PA, Reisch LM, Piepkorn MW, Barnhill RL, Elder DE, Knezevich S, Geller BM, Longton G, Elmore JG. Achieving consensus for the histopathologic diagnosis of melanocytic lesions: use of the modified Delphi method. J Cutan Pathol 2016; 43:830-7. [PMID: 27247109 DOI: 10.1111/cup.12751] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 02/16/2016] [Accepted: 03/07/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To understand the sophisticated nature of coming to consensus when diagnosing complex melanocytic lesions among a panel of experienced dermatopathologists. METHODS A total of 240 melanocytic lesions were assessed independently by three experienced dermatopathologists with their diagnoses mapped into one of five Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-DX) categories: (I) nevus/mild atypia, (II) moderate atypia, (III) severe atypia/melanoma in situ, (IV) T1a invasive melanoma and (V) ≥ T1b invasive melanoma. The dermatopathologists then discussed the cases, using a modified Delphi method to facilitated consensus building for cases with discordant diagnoses. RESULTS For most cases, a majority of interpretations (two or three of three) agreed with the consensus diagnosis in 95% of Category I, 64% of Category II, 84% of Category III, 88% for Category IV and 100% of Category V cases. Disagreements were typically due to diagnostic threshold differences (64.5%), differing contents on slides even though the slides were sequential cuts (18.5%), and missed findings (15.3%). Disagreements were resolved via discussion of histopathologic features and their significance while reviewing the slides using a multi-headed microscope, considering treatment recommendations, citing existing literature, reviewing additional slides for a case, and choosing a provisional/borderline diagnosis to capture diverse opinions. All experienced pathologists participating in this study reported that the process of coming to consensus was challenging for borderline cases and may have represented compromise rather than consensus. They also reported the process changed their approaches to diagnosing complex melanocytic lesions. CONCLUSIONS The most frequent reason for disagreement of experienced dermatopathologists was differences in diagnostic thresholds related to observer viewpoints. A range of approaches was needed to come to consensus, and this may guide pathology groups who do not currently hold consensus conferences.
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Affiliation(s)
- Patricia A Carney
- Professor of Family Medicine and of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Lisa M Reisch
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.,Dermatopathology Northwest, Bellevue, WA, USA
| | - Raymond L Barnhill
- Department of Pathology, University of California, Los Angeles, CA, USA.,Institut Curie and University of Paris Réne Descartes, Paris, France
| | - David E Elder
- Department of Pathology, University of Pennsylvania, Philadelphia, PA, USA
| | - Stevan Knezevich
- Department of Pathology, The Veterans Affairs Medical Center, Seattle, WA, USA.,Assistant Professor of Pathology, University of Washington, Seattle, WA, USA.,Pathology Associates, Clovis, CA, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Gary Longton
- Fred Hutchison Cancer Research Center, Seattle, WA, USA
| | - Joann G Elmore
- Professor of Internal Medicine, University of Washington, Seattle, WA, USA
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10
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Elmore JG, Cook AJ, Bogart A, Carney PA, Geller BM, Taplin SH, Buist DSM, Onega T, Lee CI, Miglioretti DL. Radiologists' interpretive skills in screening vs. diagnostic mammography: are they related? Clin Imaging 2016; 40:1096-1103. [PMID: 27438069 DOI: 10.1016/j.clinimag.2016.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/03/2016] [Accepted: 06/29/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE This study aims to determine whether radiologists who perform well in screening also perform well in interpreting diagnostic mammography. MATERIALS AND METHODS We evaluated the accuracy of 468 radiologists interpreting 2,234,947 screening and 196,164 diagnostic mammograms. Adjusting for site, radiologist, and patient characteristics, we identified radiologists with performance in the highest tertile and compared to those with lower performance. RESULTS A moderate correlation was noted for radiologists' accuracy when interpreting screening versus their accuracy on diagnostic examinations: sensitivity (rspearman=0.51, 95% CI: 0.22, 0.80; P=.0006) and specificity (rspearman=0.40, 95% CI: 0.30, 0.49; P<.0001). CONCLUSION Different educational approaches to screening and diagnostic imaging should be considered.
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Affiliation(s)
- Joann G Elmore
- Division of General Internal Medicine, University of Washington, 325 Ninth Avenue, Box 359780, Seattle, WA, 98104, USA.
| | - Andrea J Cook
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Andy Bogart
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: FM, Portland, OR, 97239, USA
| | - Berta M Geller
- University of Vermont, 1 South Prospect Street, UHC, Burlington, VT, 05401, USA
| | - Stephen H Taplin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute National Institutes of Health, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Diana S M Buist
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Tracy Onega
- Dartmouth Medical School, One Medical Center Drive, HB7937, Lebanon, NH, 03756, USA
| | - Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, 825 Eastlake Avenue E, G3-200, Seattle, WA, 98109, USA; Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St., Box 357660, Seattle, WA, 98195, USA
| | - Diana L Miglioretti
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA; Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, One Shields Avenue, Med Sci 1C, Room 144, Davis, CA, 95616, USA
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11
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Oh H, Bodelon C, Palakal M, Chatterjee N, Sherman ME, Linville L, Geller BM, Vacek PM, Weaver DL, Chicoine RE, Papathomas D, Patel DA, Xiang J, Clare SE, Visscher DW, Mies C, Hewitt SM, Brinton LA, Storniolo AMV, He C, Garcia-Closas M, Chanock SJ, Gierach GL, Figueroa JD. Ages at menarche- and menopause-related genetic variants in relation to terminal duct lobular unit involution in normal breast tissue. Breast Cancer Res Treat 2016; 158:341-50. [PMID: 27342457 DOI: 10.1007/s10549-016-3859-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/07/2016] [Indexed: 12/21/2022]
Abstract
Reduced levels of terminal duct lobular unit (TDLU) involution, as reflected by higher numbers of TDLUs and acini per TDLU, have been associated with higher breast cancer risk. Younger age at menarche and older age at menopause have been previously related to lower levels of TDLU involution. To determine a possible genetic link, we examined whether single-nucleotide polymorphisms (SNPs) previously established in genome-wide association studies (GWAS) for ages at menarche and menopause are associated with TDLU involution. We conducted a pooled analysis of 862 women from two studies. H&E tissue sections were assessed for numbers of TDLUs and acini/TDLU. Poisson regression models were used to estimate associations of 36 menarche- and 21 menopause-SNPs with TDLU counts, acini counts/TDLU, and the product of these two measures, adjusting for age and study site. Fourteen percent of evaluated SNPs (eight SNPs) were associated with TDLU counts at p < 0.05, suggesting an enrichment of associations with TDLU counts. However, only menopause-SNPs had >50 % that were either significantly or nonsignificantly associated with TDLU measures in the directions consistent with their relationships shown in GWAS. Among ten SNPs that were statistically significantly associated with at least one TDLU involution measure (p < 0.05), seven SNPs (rs466639: RXRG; rs2243803: SLC14A2; rs2292573: GAB2; rs6438424: 3q13.32; rs7606918: METAP1D; rs11668344: TMEM150B; rs1635501: EXO1) were associated in the consistent directions. Our data suggest that the loci associated with ages at menarche and menopause may influence TDLU involution, suggesting some shared genetic mechanisms. However, larger studies are needed to confirm the results.
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Affiliation(s)
- Hannah Oh
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA.
| | - Clara Bodelon
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Maya Palakal
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Nilanjan Chatterjee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Mark E Sherman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA.,Division of Cancer Prevention, National Cancer Institute, Bethesda, MD, USA
| | - Laura Linville
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | | | | | | | | | - Daphne Papathomas
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Deesha A Patel
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Jackie Xiang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Susan E Clare
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel W Visscher
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Carolyn Mies
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Genomic Health, Inc., Redwood City, CA, USA
| | - Stephen M Hewitt
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Louise A Brinton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Anna Maria V Storniolo
- Susan G. Komen Tissue Bank at the Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Chunyan He
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA.,Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Montserrat Garcia-Closas
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Stephen J Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Gretchen L Gierach
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA
| | - Jonine D Figueroa
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD, 20892, USA.,Usher Institute of Population Health Sciences and Informatics, Institute of Genomics and Molecular Medicine, Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
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12
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Carney PA, Frederick PD, Reisch LM, Knezevich S, Piepkorn MW, Barnhill RL, Elder DE, Geller BM, Titus L, Weinstock MA, Nelson HD, Elmore JG. How concerns and experiences with medical malpractice affect dermatopathologists' perceptions of their diagnostic practices when interpreting cutaneous melanocytic lesions. J Am Acad Dermatol 2015; 74:317-24; quiz 324.e1-8. [PMID: 26559597 DOI: 10.1016/j.jaad.2015.09.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 09/11/2015] [Accepted: 09/16/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We sought to identify characteristics associated with past malpractice lawsuits and how malpractice concerns may affect interpretive practices. METHODS We surveyed 207 of 301 (68.8%) eligible dermatopathologists who interpret melanocytic skin lesions in 10 states. The survey assessed dermatopathologists' demographic and clinical practice characteristics, perceptions of how medical malpractice concerns could influence their interpretive practices, and past malpractice lawsuits. RESULTS Of dermatopathologists, 33% reported past malpractice experiences. Factors associated with being sued included older age (57 vs 48 years, P < .001), lack of board certification or fellowship training in dermatopathology (76.5% vs 53.2%, P = .001), and greater number of years interpreting melanocytic lesions (>20 years: 52.9% vs 20.1%, P < .001). Of participants, 64% reported being moderately or extremely confident in their melanocytic interpretations. Although most dermatopathologists believed that malpractice concerns increased their likelihood of ordering specialized pathology tests, obtaining recuts, and seeking a second opinion, none of these practices were associated with past malpractice. Most dermatopathologists reported concerns about potential harms to patients that may result from their assessments of melanocytic lesions. LIMITATIONS Limitations of this study include lack of validation of and details about the malpractice suits experienced by participating dermatopathologists. In addition, the study assessed perceptions of practice rather than actual practices that might be associated with malpractice incidents. CONCLUSIONS Most dermatopathologists reported apprehension about how malpractice affects their clinical practice and are concerned about patient safety irrespective of whether they had actually experienced a medical malpractice suit.
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Affiliation(s)
- Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon.
| | - Paul D Frederick
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Lisa M Reisch
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | | | - Michael W Piepkorn
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Dermatopathology Northwest, Bellevue, Washington
| | - Raymond L Barnhill
- Department of Pathology, University of California, Los Angeles, California; Department of Pathology, Institut Curie, Paris, France
| | - David E Elder
- Pathology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Berta M Geller
- Family Medicine, University of Vermont, Burlington, Vermont
| | - Linda Titus
- Epidemiology and of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Martin A Weinstock
- Dermatology and Epidemiology, Center for Dermatoepidemiology, Department of Veterans Affairs Medical Center, Providence, Rhode Island; Department of Dermatology, Rhode Island Hospital, Providence, Rhode Island; Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon; Department of Medicine, Oregon Health and Science University, Portland, Oregon; Cancer Prevention and Screening, Providence Cancer Center, Providence Health and Services Oregon, Portland, Oregon
| | - Joann G Elmore
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
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13
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Onega T, Goldman LE, Walker RL, Miglioretti DL, Buist DS, Taplin S, Geller BM, Hill DA, Smith-Bindman R. Facility Mammography Volume in Relation to Breast Cancer Screening Outcomes. J Med Screen 2015; 23:31-7. [PMID: 26265482 DOI: 10.1177/0969141315595254] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To clarify the relationship between facility-level mammography interpretive volume and breast cancer screening outcomes. METHODS We calculated annual mammography interpretive volumes from 2000-2009 for 116 facilities participating in the U.S. Breast Cancer Surveillance Consortium (BCSC). Radiology, pathology, cancer registry, and women's self-report information were used to determine the indication for each exam, cancer characteristics, and patient characteristics. We examined the effect of annual total volume and percentage of mammograms that were screening on cancer detection rates using multinomial logistic regression adjusting for age, race/ethnicity, time since last mammogram, and BCSC registries. "Good prognosis" tumours were defined as screen-detected invasive cancers that were <15 mm, early stage, and lymph node negative at diagnosis. RESULTS From 3,098,481 screening mammograms, 9,899 cancers were screen-detected within one year of the exam. Approximately 80% of facilities had annual total interpretive volumes of >2,000 mammograms, and 42% had >5,000. Higher total volume facilities were significantly more likely to diagnose invasive tumours with good prognoses (odds ratio [OR] 1.32; 95% confidence interval [CI] 1.10-1.60, for total volume of 5,000-10,000/year v. 1,000-2,000/year; p-for-trend <0.001). A concomitant decrease in tumours with poor prognosis was seen (OR 0.78; 95%CI 0.63-0.98 for total volume of 5,000-10,000/year v. 1,000-2,000/year). CONCLUSIONS Mammography facilities with higher total interpretive volumes detected more good prognosis invasive tumours and fewer poor prognosis invasive tumours, suggesting that women attending these facilities may be more likely to benefit from screening.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Rod L Walker
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - Diana L Miglioretti
- Group Health Research Institute, Group Health Cooperative, Seattle, WA Department of Public Health Sciences, University of California, Davis, CA
| | - Diana Sm Buist
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | | | - Berta M Geller
- Department of Radiology and Office of Health Promotion Research, University of Vermont, Burlington, VT
| | - Deirdre A Hill
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM
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14
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Gierach GL, Patel DA, Falk RT, Pfeiffer RM, Geller BM, Vacek PM, Weaver DL, Chicoine RE, Shepherd JA, Mahmoudzadeh AP, Wang J, Fan B, Herschorn SD, Xu X, Veenstra T, Fuhrman B, Sherman ME, Brinton LA. Relationship of serum estrogens and metabolites with area and volume mammographic densities. Horm Cancer 2015; 6:107-19. [PMID: 25757805 PMCID: PMC4558904 DOI: 10.1007/s12672-015-0216-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 01/29/2015] [Indexed: 12/12/2022]
Abstract
Elevated mammographic density is a breast cancer risk factor, which has a suggestive, but unproven, relationship with increased exposure to sex steroid hormones. We examined associations of serum estrogens and estrogen metabolites with area and novel volume mammographic density measures among 187 women, ages 40-65, undergoing diagnostic breast biopsies at an academic facility in Vermont. Serum parent estrogens, estrone and estradiol, and their 2-, 4-, and 16-hydroxylated metabolites were measured using liquid chromatography-tandem mass spectrometry. Area mammographic density was measured in the breast contralateral to the biopsy using thresholding software; volume mammographic density was quantified using a density phantom. Linear regression was used to estimate associations of estrogens with mammographic densities, adjusted for age and body mass index, and stratified by menopausal status and menstrual cycle phase. Weak, positive associations between estrogens, estrogen metabolites, and mammographic density were observed, primarily among postmenopausal women. Among premenopausal luteal phase women, the 16-pathway metabolite estriol was associated with percent area (p = 0.04) and volume (p = 0.05) mammographic densities and absolute area (p = 0.02) and volume (p = 0.05) densities. Among postmenopausal women, levels of total estrogens, the sum of parent estrogens, and 2-, 4- and 16-hydroxylation pathway metabolites were positively associated with area density measures (percent: p = 0.03, p = 0.04, p = 0.01, p = 0.02, p = 0.07; absolute: p = 0.02, p = 0.02, p = 0.01, p = 0.02, p = 0.03, respectively) but not volume density measures. Our data suggest that serum estrogen profiles are weak determinants of mammographic density and that analysis of different density metrics may provide complementary information about relationships of estrogen exposure to breast tissue composition.
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Affiliation(s)
- Gretchen L. Gierach
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
- 9609 Medical Center Drive, Rm. 7-E108, Bethesda, MD 20892-9774 USA
| | - Deesha A. Patel
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - Roni T. Falk
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - Ruth M. Pfeiffer
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | | | | | | | | | | | | | - Jeff Wang
- University of California, San Francisco, San Francisco, CA USA
- Present Address: Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Bo Fan
- University of California, San Francisco, San Francisco, CA USA
| | | | - Xia Xu
- Laboratory of Proteomics and Analytical Technologies, Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD USA
| | - Timothy Veenstra
- Laboratory of Proteomics and Analytical Technologies, Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD USA
- Present Address: CN Diagnostics, 4041 Forest Park Avenue, Saint Louis, MO USA
| | - Barbara Fuhrman
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Mark E. Sherman
- Breast and Gynecologic Cancer Research Group, Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - Louise A. Brinton
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
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15
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Elmore JG, Longton GM, Carney PA, Geller BM, Onega T, Tosteson ANA, Nelson HD, Pepe MS, Allison KH, Schnitt SJ, O'Malley FP, Weaver DL. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA 2015; 313:1122-32. [PMID: 25781441 PMCID: PMC4516388 DOI: 10.1001/jama.2015.1405] [Citation(s) in RCA: 351] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE A breast pathology diagnosis provides the basis for clinical treatment and management decisions; however, its accuracy is inadequately understood. OBJECTIVES To quantify the magnitude of diagnostic disagreement among pathologists compared with a consensus panel reference diagnosis and to evaluate associated patient and pathologist characteristics. DESIGN, SETTING, AND PARTICIPANTS Study of pathologists who interpret breast biopsies in clinical practices in 8 US states. EXPOSURES Participants independently interpreted slides between November 2011 and May 2014 from test sets of 60 breast biopsies (240 total cases, 1 slide per case), including 23 cases of invasive breast cancer, 73 ductal carcinoma in situ (DCIS), 72 with atypical hyperplasia (atypia), and 72 benign cases without atypia. Participants were blinded to the interpretations of other study pathologists and consensus panel members. Among the 3 consensus panel members, unanimous agreement of their independent diagnoses was 75%, and concordance with the consensus-derived reference diagnoses was 90.3%. MAIN OUTCOMES AND MEASURES The proportions of diagnoses overinterpreted and underinterpreted relative to the consensus-derived reference diagnoses were assessed. RESULTS Sixty-five percent of invited, responding pathologists were eligible and consented to participate. Of these, 91% (N = 115) completed the study, providing 6900 individual case diagnoses. Compared with the consensus-derived reference diagnosis, the overall concordance rate of diagnostic interpretations of participating pathologists was 75.3% (95% CI, 73.4%-77.0%; 5194 of 6900 interpretations). Among invasive carcinoma cases (663 interpretations), 96% (95% CI, 94%-97%) were concordant, and 4% (95% CI, 3%-6%) were underinterpreted; among DCIS cases (2097 interpretations), 84% (95% CI, 82%-86%) were concordant, 3% (95% CI, 2%-4%) were overinterpreted, and 13% (95% CI, 12%-15%) were underinterpreted; among atypia cases (2070 interpretations), 48% (95% CI, 44%-52%) were concordant, 17% (95% CI, 15%-21%) were overinterpreted, and 35% (95% CI, 31%-39%) were underinterpreted; and among benign cases without atypia (2070 interpretations), 87% (95% CI, 85%-89%) were concordant and 13% (95% CI, 11%-15%) were overinterpreted. Disagreement with the reference diagnosis was statistically significantly higher among biopsies from women with higher (n = 122) vs lower (n = 118) breast density on prior mammograms (overall concordance rate, 73% [95% CI, 71%-75%] for higher vs 77% [95% CI, 75%-80%] for lower, P < .001), and among pathologists who interpreted lower weekly case volumes (P < .001) or worked in smaller practices (P = .034) or nonacademic settings (P = .007). CONCLUSIONS AND RELEVANCE In this study of pathologists, in which diagnostic interpretation was based on a single breast biopsy slide, overall agreement between the individual pathologists' interpretations and the expert consensus-derived reference diagnoses was 75.3%, with the highest level of concordance for invasive carcinoma and lower levels of concordance for DCIS and atypia. Further research is needed to understand the relationship of these findings with patient management.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Gary M Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Vineyard Haven, Massachusetts
| | - Tracy Onega
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Anna N A Tosteson
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire6Department of Medicine, Geisel School of Medicine at
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, Portland8Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland9Department of Clinical Epidemiology and Medicine, Oregon Health and Scien
| | - Margaret S Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Stuart J Schnitt
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts12Harvard Medical School, Boston, Massachusetts
| | - Frances P O'Malley
- Department of Laboratory Medicine and the Keenan Research Centre of the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada14St Michael's Hospital and the University of Toronto, Ontario, Canada
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington
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Allison KH, Abraham LA, Weaver DL, Tosteson ANA, Nelson HD, Onega T, Geller BM, Kerlikowske K, Carney PA, Ichikawa LE, Buist DSM, Elmore JG. Trends in breast biopsy pathology diagnoses among women undergoing mammography in the United States: a report from the Breast Cancer Surveillance Consortium. Cancer 2015; 121:1369-78. [PMID: 25603785 DOI: 10.1002/cncr.29199] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/14/2014] [Accepted: 10/21/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Current data on the pathologic diagnoses of breast biopsy after mammography can inform patients, clinicians, and researchers about important population trends. METHODS Breast Cancer Surveillance Consortium data on 4,020,140 mammograms between 1996 and 2008 were linked to 76,567 pathology specimens. Trends in diagnoses in biopsies by time and risk factors (patient age, breast density, and family history of breast cancer) were examined for screening and diagnostic mammography (performed for a breast symptom or short-interval follow-up). RESULTS Of the total mammograms, 88.5% were screening and 11.5% diagnostic; 1.2% of screening and 6.8% of diagnostic mammograms were followed by biopsies. The frequency of biopsies over time was stable after screening mammograms, but increased after diagnostic mammograms. For biopsies obtained after screening, frequencies of invasive carcinoma increased over time for women ages 40-49 and 60-69, Ductal carcinoma in situ (DCIS) increased for those ages 40-69, whereas benign diagnoses decreased for all ages. No trends in pathology diagnoses were found following diagnostic mammograms. Dense breast tissue was associated with high-risk lesions and DCIS relative to nondense breast tissue. Family history of breast cancer was associated with DCIS and invasive cancer. CONCLUSIONS Although the frequency of breast biopsy after screening mammography has not changed over time, the percentages of biopsies with DCIS and invasive cancer diagnoses have increased. Among biopsies following mammography, women with dense breasts or family history of breast cancer were more likely to have high-risk lesions or invasive cancer. These findings are relevant to breast cancer screening and diagnostic practices.
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Affiliation(s)
- Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, California
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17
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Johnson JM, Johnson AK, O'Meara ES, Miglioretti DL, Geller BM, Hotaling EN, Herschorn SD. Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results. Radiology 2014; 275:54-60. [PMID: 25423143 DOI: 10.1148/radiol.14140036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To compare the cancer detection rate and stage after benign stereotactic or ultrasonography (US)-guided core breast biopsy between patients with short-interval follow-up (SIFU) and those who return to annual screening. MATERIALS AND METHODS The Breast Cancer Surveillance Consortium (BCSC) registry and the BCSC Statistical Coordinating Center received institutional review board approval for active and passive consent processes and a waiver of consent. All procedures were HIPAA compliant. BCSC data for 1994-2010 were used to compare ipsilateral breast cancer detection rates and tumor characteristics for diagnoses within 3 months after SIFU (3-8 months) versus return to annual screening (RTAS) mammography (9-18 months) after receiving a benign pathology result from image-guided breast biopsy. RESULTS In total, 17 631 biopsies with benign findings were identified with SIFU or RTAS imaging. In the SIFU group, 27 ipsilateral breast cancers were diagnosed in 10 715 mammographic examinations (2.5 cancers per 1000 examinations) compared with 16 cancers in 6916 mammographic examinations in the RTAS group (2.3 cancers per 1000 examinations) (P = .88). Sixteen cancers after SIFU (59%; 95% confidence interval [CI]: 39%, 78%) were invasive versus 12 after RTAS (75%; 95% CI: 48%, 93%). The invasive cancer rate was 1.5 per 1000 examinations after SIFU (95% CI: 0.9, 2.4) and 1.7 per 1000 examinations (95% CI: 0.9, 3.0) after RTAS (P = .70). Among invasive cancers, 25% were late stage (stage 2B, 3, or 4) in the SIFU group (95% CI: 7%, 52%) versus 27% in the RTAS group (95% CI: 6%, 61%). Positive lymph nodes were found in seven (44%; 95% CI: 20%, 70%) invasive cancers after SIFU and in three (25%; 95% CI: 5%, 57%) invasive cancers after RTAS. CONCLUSION Similar rates of cancer detection were found between SIFU and RTAS after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.
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Affiliation(s)
- Jason M Johnson
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (J.M.J.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (A.K.J.); Group Health Research Institute, Seattle, Wash (E.S.O., D.L.M.); and Division of Breast Imaging, Department of Radiology, Fletcher Allen Health Care, Burlington, Vt (B.M.G., E.N.H., S.D.H.)
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18
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Geller BM, Vacek PM, Flynn BS, Lord K, Cranmer D. What are cancer survivors' needs and how well are they being met? J Fam Pract 2014; 63:E7-E16. [PMID: 25343160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE This study sought to identify the needs and unmet needs of the growing number of adult cancer survivors. METHODS Vermont survivor advocates partnered with academic researchers to create a survivor registry and conduct a cross-sectional survey of cancer-related needs and unmet needs of adult survivors. The mailed survey addressed 53 specific needs in 5 domains based on prior research, contributions from the research partners, and pilot testing. Results were summarized by computing proportions who reported having needs met or unmet. RESULTS Survey participants included 1668 of 2005 individuals invited from the survivor registry (83%); 65.7% were ages 60 or older and 61.9% were women. These participants had received their diagnosis 2 to 16 years earlier; 77.5% had been diagnosed ≥5 years previously; 30.2% had at least one unmet need in the emotional, social, and spiritual (E) domain; just 14.4% had at least one unmet need in the economic and legal domain. The most commonly identified individual unmet needs were in the E and the information (I) domains and included “help reducing stress” (14.8% of all respondents) and “information about possible after effects of treatment” (14.4%). CONCLUSIONS Most needs of these longerterm survivors were met, but substantial proportions of survivors identified unmet needs. Unmet needs such as information about late and long-term adverse effects of treatment could be met within clinical care with a cancer survivor care plan, but some survivors may require referral to services focused on stress and coping.
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Affiliation(s)
- Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, USA.
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19
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Feng S, Weaver DL, Carney PA, Reisch LM, Geller BM, Goodwin A, Rendi MH, Onega T, Allison KH, Tosteson ANA, Nelson HD, Longton G, Pepe M, Elmore JG. A framework for evaluating diagnostic discordance in pathology discovered during research studies. Arch Pathol Lab Med 2014; 138:955-61. [PMID: 24978923 DOI: 10.5858/arpa.2013-0263-oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Little is known about the frequency of discordant diagnoses identified during research. OBJECTIVE To describe diagnostic discordance identified during research and apply a newly designed research framework for investigating discordance. DESIGN Breast biopsy cases (N = 407) from registries in Vermont and New Hampshire were independently reviewed by a breast pathology expert. The following research framework was developed to assess those cases: (1) compare the expert review and study database diagnoses, (2) determine the clinical significance of diagnostic discordance, (3) identify and correct data errors and verify the existence of true diagnostic discrepancies, (4) consider the impact of borderline cases, and (5) determine the notification approach for verified disagreements. RESULTS Initial overall discordance between the original diagnosis recorded in our research database and a breast pathology expert was 32.2% (131 of 407). This was reduced to less than 10% after following the 5-step research framework. Detailed review identified 12 cases (2.9%) with data errors (2 in the underlying pathology registry, 3 with incomplete slides sent for expert review, and 7 with data abstraction errors). After excluding the cases with data errors, 38 cases (9.6%) among the remaining 395 had clinically meaningful discordant diagnoses (κ = 0.82; SE, 0.04; 95% confidence interval, 0.76-0.87). Among these 38 cases, 20 (53%) were considered borderline between 2 diagnoses by either the original pathologist or the expert. We elected to notify the pathology registries and facilities regarding discordant diagnoses. CONCLUSIONS Understanding the types and sources of diagnostic discordance uncovered in research studies may lead to improved scientific data and better patient care.
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Affiliation(s)
- Sherry Feng
- From the School of Medicine (Ms Feng), the Division of General Internal Medicine (Dr Reisch and Dr Elmore), and the Department of Anatomic Pathology (Dr Rendi), University of Washington, Seattle; the Departments of Pathology, College of Medicine, and the Vermont Cancer Center (Dr Weaver), Family Medicine and Radiology (Dr Geller), and Pathology (Dr Goodwin), University of Vermont, Burlington; the Departments of Family Medicine and Public Health & Preventive Medicine (Dr Carney) and Medical Informatics & Clinical Epidemiology and Medicine (Dr Nelson), Oregon Health and Science University, Portland; the Section of Biostatistics and Epidemiology (Dr Onega), and the Department of Community & Family Medicine (Dr Tosteson), Dartmouth College, Lebanon, New Hampshire; the Department of Pathology, Stanford University, Stanford, California (Dr Allison); Biostatistics Modeling and Methods (Mr Longton) and Biostatistics and Biomathematics (Dr Pepe), Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle
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20
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Gierach GL, Geller BM, Shepherd JA, Patel DA, Vacek PM, Weaver DL, Chicoine RE, Pfeiffer RM, Fan B, Mahmoudzadeh AP, Wang J, Johnson JM, Herschorn SD, Brinton LA, Sherman ME. Comparison of mammographic density assessed as volumes and areas among women undergoing diagnostic image-guided breast biopsy. Cancer Epidemiol Biomarkers Prev 2014; 23:2338-48. [PMID: 25139935 DOI: 10.1158/1055-9965.epi-14-0257] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Mammographic density (MD), the area of non-fatty-appearing tissue divided by total breast area, is a strong breast cancer risk factor. Most MD analyses have used visual categorizations or computer-assisted quantification, which ignore breast thickness. We explored MD volume and area, using a volumetric approach previously validated as predictive of breast cancer risk, in relation to risk factors among women undergoing breast biopsy. METHODS Among 413 primarily white women, ages 40 to 65 years, undergoing diagnostic breast biopsies between 2007 and 2010 at an academic facility in Vermont, MD volume (cm(3)) was quantified in craniocaudal views of the breast contralateral to the biopsy target using a density phantom, whereas MD area (cm(2)) was measured on the same digital mammograms using thresholding software. Risk factor associations with continuous MD measurements were evaluated using linear regression. RESULTS Percent MD volume and area were correlated (r = 0.81) and strongly and inversely associated with age, body mass index (BMI), and menopause. Both measures were inversely associated with smoking and positively associated with breast biopsy history. Absolute MD measures were correlated (r = 0.46) and inversely related to age and menopause. Whereas absolute dense area was inversely associated with BMI, absolute dense volume was positively associated. CONCLUSIONS Volume and area MD measures exhibit some overlap in risk factor associations, but divergence as well, particularly for BMI. IMPACT Findings suggest that volume and area density measures differ in subsets of women; notably, among obese women, absolute density was higher with volumetric methods, suggesting that breast cancer risk assessments may vary for these techniques.
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Affiliation(s)
- Gretchen L Gierach
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland.
| | | | - John A Shepherd
- University of California, San Francisco, San Francisco, California
| | - Deesha A Patel
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | | | | | | | - Ruth M Pfeiffer
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Bo Fan
- University of California, San Francisco, San Francisco, California
| | | | - Jeff Wang
- University of California, San Francisco, San Francisco, California
| | | | | | - Louise A Brinton
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Mark E Sherman
- Breast and Gynecologic Cancer Research Group, Division of Cancer Prevention, National Cancer Institute, NIH, Bethesda, Maryland
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21
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Geller BM, Nelson HD, Carney PA, Weaver DL, Onega T, Allison KH, Frederick PD, Tosteson ANA, Elmore JG. Second opinion in breast pathology: policy, practice and perception. J Clin Pathol 2014; 67:955-60. [PMID: 25053542 DOI: 10.1136/jclinpath-2014-202290] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIMS To assess the laboratory policies, pathologists' clinical practice and perceptions about the value of second opinions for breast pathology cases among pathologists practising in the USA. METHODS Cross-sectional data were collected from 252 pathologists who interpret breast specimens in eight states using a web-based survey. Descriptive statistics were used to characterise findings. RESULTS Most participants had >10 years of experience interpreting breast specimens (64%), were not affiliated with academic centres (73%) and were not considered experts by their peers (79%). Laboratory policies mandating second opinions varied by diagnosis: invasive cancer 65%; ductal carcinoma in situ (DCIS) 56%; atypical ductal hyperplasia 36% and other benign cases 33%. 81% obtained second opinions in the absence of policies. Participants believed they improve diagnostic accuracy (96%) and protect from malpractice suits (83%), and were easy to obtain, did not take too much time and did not make them look less adequate. The most common (60%) approach to resolving differences between the first and second opinion is to ask for a third opinion, followed by reaching a consensus. CONCLUSIONS Laboratory-based second opinion policies vary for breast pathology but are most common for invasive cancer and DCIS cases. Pathologists have favourable attitudes towards second opinions, adhere to policies and obtain them even when policies are absent. Those without a formal policy may benefit from supportive clinical practices and systems that help obtain second opinions.
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Affiliation(s)
- Berta M Geller
- Department of Family Medicine, OHPR, University of Vermont, Burlington, Vermont, USA
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Donald L Weaver
- Department of Pathology, University of Vermont and Vermont Cancer Center, Burlington, Vermont, USA
| | - Tracy Onega
- Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Anna N A Tosteson
- Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Bolton KC, Mace JL, Vacek PM, Herschorn SD, James TA, Tice JA, Kerlikowske K, Geller BM, Weaver DL, Sprague BL. Changes in breast cancer risk distribution among Vermont women using screening mammography. J Natl Cancer Inst 2014; 106:dju157. [PMID: 24957223 DOI: 10.1093/jnci/dju157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Screening mammography utilization in Vermont has declined since 2009 during a time of changing screening guidelines and increased interest in personalized screening regimens. This study evaluates whether the breast cancer risk distribution of the state's screened population changed during the observed decline. METHODS We examined the breast cancer risk distribution among screened women between 2001 and 2012 using data from the Vermont Breast Cancer Surveillance System. We estimated each screened woman's 5-year risk of breast cancer using the Breast Cancer Surveillance Consortium risk calculator. Annual screening counts by risk group were normalized and age-adjusted to the Vermont female population by direct standardization. RESULTS The normalized rate of low-risk (5-year breast cancer risk of <1%) women screened increased 8.3% per year (95% confidence interval [CI] = 4.8 to 11.9) between 2003 and 2008 and then declined by -5.4% per year (95% CI = -8.1 to -2.6) until 2012. When stratified by age group, the rate of low-risk women screened declined -4.4% per year (95% CI = -8.8 to 0.1; not statistically significant) for ages 40 to 49 years and declined a statistically significant -7.1% per year (95% CI = -12.1 to -2.0) for ages 50 to 74 years during 2008 to 2012. These declines represented the bulk of overall decreases in screening after 2008, with rates for women categorized in higher risk levels generally exhibiting small annual changes. CONCLUSIONS The observed decline in women screened in Vermont in recent years is largely attributable to reductions in screening visits by women who are at low risk of developing breast cancer.
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Affiliation(s)
- Kenyon C Bolton
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - John L Mace
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Pamela M Vacek
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Sally D Herschorn
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Ted A James
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Jeffrey A Tice
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Karla Kerlikowske
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Berta M Geller
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Donald L Weaver
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA
| | - Brian L Sprague
- Affiliations of authors: Office of Health Promotion Research (KCB, JLM, BMG, BLS), Department of Biostatistics (PMV), Vermont Cancer Center (PMV, SDH, TAJ, DLW, BLS), Department of Radiology (SDH), Department of Surgery (TAJ, BLS), Department of Family Medicine (BMG), and Department of Pathology (DLW), University of Vermont, Burlington, VT; Departments of Medicine and Epidemiology and Biostatistics (JAT, KK), and General Internal Medicine Section (KK), Department of Veterans Affairs, University of California, San Francisco, CA.
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Buist DSM, Anderson ML, Smith RA, Carney PA, Miglioretti DL, Monsees BS, Sickles EA, Taplin SH, Geller BM, Yankaskas BC, Onega TL. Effect of radiologists' diagnostic work-up volume on interpretive performance. Radiology 2014; 273:351-64. [PMID: 24960110 DOI: 10.1148/radiol.14132806] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine radiologists' screening performance in relation to the number of diagnostic work-ups performed after abnormal findings are discovered at screening mammography by the same radiologist or by different radiologists. MATERIALS AND METHODS In an institutional review board-approved HIPAA-compliant study, the authors linked 651 671 screening mammograms interpreted from 2002 to 2006 by 96 radiologists in the Breast Cancer Surveillance Consortium to cancer registries (standard of reference) to evaluate the performance of screening mammography (sensitivity, false-positive rate [ FPR false-positive rate ], and cancer detection rate [ CDR cancer detection rate ]). Logistic regression was used to assess the association between the volume of recalled screening mammograms ("own" mammograms, where the radiologist who interpreted the diagnostic image was the same radiologist who had interpreted the screening image, and "any" mammograms, where the radiologist who interpreted the diagnostic image may or may not have been the radiologist who interpreted the screening image) and screening performance and whether the association between total annual volume and performance differed according to the volume of diagnostic work-up. RESULTS Annually, 38% of radiologists performed the diagnostic work-up for 25 or fewer of their own recalled screening mammograms, 24% performed the work-up for 0-50, and 39% performed the work-up for more than 50. For the work-up of recalled screening mammograms from any radiologist, 24% of radiologists performed the work-up for 0-50 mammograms, 32% performed the work-up for 51-125, and 44% performed the work-up for more than 125. With increasing numbers of radiologist work-ups for their own recalled mammograms, the sensitivity (P = .039), FPR false-positive rate (P = .004), and CDR cancer detection rate (P < .001) of screening mammography increased, yielding a stepped increase in women recalled per cancer detected from 17.4 for 25 or fewer mammograms to 24.6 for more than 50 mammograms. Increases in work-ups for any radiologist yielded significant increases in FPR false-positive rate (P = .011) and CDR cancer detection rate (P = .001) and a nonsignificant increase in sensitivity (P = .15). Radiologists with a lower annual volume of any work-ups had consistently lower FPR false-positive rate , sensitivity, and CDR cancer detection rate at all annual interpretive volumes. CONCLUSION These findings support the hypothesis that radiologists may improve their screening performance by performing the diagnostic work-up for their own recalled screening mammograms and directly receiving feedback afforded by means of the outcomes associated with their initial decision to recall. Arranging for radiologists to work up a minimum number of their own recalled cases could improve screening performance but would need systems to facilitate this workflow.
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Affiliation(s)
- Diana S M Buist
- From the Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101 (D.S.M.B., M.L.A., D.L.M.); Cancer Control Science Department, American Cancer Society, Atlanta, Ga (R.A.S.); Departments of Family Medicine and Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Ore (P.A.C.); Department of Biostatistics, University of Washington School of Public Health, Seattle, Wash (D.L.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (B.S.M.); Department of Radiology, University of California, San Francisco, Calif (E.A.S.); Division of Cancer Control and Population Science, Behavioral Research Program, National Cancer Institute, Rockville, Md (S.H.T.); Department of Family Medicine, University of Vermont, College of Medicine, Burlington, Vt (B.M.G.); Department of Radiology, University of North Carolina, Chapel Hill, NC (B.C.Y.); and Department of Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH (T.L.O.)
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Dulko D, Pace CM, Dittus KL, Sprague BL, Pollack LA, Hawkins NA, Geller BM. Barriers and facilitators to implementing cancer survivorship care plans. Oncol Nurs Forum 2014; 40:575-80. [PMID: 24161636 DOI: 10.1188/13.onf.575-580] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE/OBJECTIVES To evaluate the process of survivorship care plan (SCP) completion and to survey oncology staff and primary care physicians (PCPs) regarding challenges of implementing SCPs. DESIGN Descriptive pilot study. SETTING Two facilities in Vermont, an urban academic medical center and a rural community academic cancer center. SAMPLE 17 oncology clinical staff created SCPs, 39 PCPs completed surveys, and 58 patients (breast or colorectal cancer) participated in a telephone survey. METHODS Using Journey Forward tools, SCPs were created and presented to patients. PCPs received the SCP with a survey assessing its usefulness and barriers to delivery. Oncology staff were interviewed to assess perceived challenges and benefits of SCPs. Qualitative and quantitative data were used to identify challenges to the development and implementation process as well as patient perceptions of the SCP visit. MAIN RESEARCH VARIABLES SCP, healthcare provider perception of barriers to completion and implementation, and patient perception of SCP visit. FINDINGS Oncology staff cited the time required to obtain information for SCPs as a challenge. Completing SCPs 3-6 months after treatment ended was optimal. All participants felt advanced practice professionals should complete and review SCPs with patients. The most common challenge for PCPs to implement SCP recommendations was insufficient knowledge of cancer survivor issues. Most patients found the care plan visit very useful, particularly within six months of diagnosis. CONCLUSIONS Creation time may be a barrier to widespread SCP implementation. Cancer survivors find SCPs useful, but PCPs feel insufficient knowledge of cancer survivor issues is a barrier to providing best follow-up care. Incorporating SCPs in electronic medical records may facilitate patient identification, appropriate staff scheduling, and timely SCP creation. IMPLICATIONS FOR NURSING Oncology nurse practitioners are well positioned to create and deliver SCPs, transitioning patients from oncology care to a PCP in a shared-care model of optimal wellness. Institution support for the time needed for SCP creation and review is imperative for sustaining this initiative. KNOWLEDGE TRANSLATION Accessing complete medical records is an obstacle for completing SCPs. A 3-6 month window to develop and deliver SCPs may be ideal. PCPs perceive insufficient knowledge of cancer survivor issues as a barrier to providing appropriate follow-up care.
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Dittus KL, Sprague BL, Pace CM, Dulko DA, Pollack LA, Hawkins NA, Geller BM. Primary Care Provider Evaluation of Cancer Survivorship Care Plans Developed for Patients in their Practice. ACTA ACUST UNITED AC 2014; 2:163. [PMID: 26451385 PMCID: PMC4595165 DOI: 10.4172/2329-9126.1000163] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Survivorship care plans (SCP), which describe a cancer survivor's diagnosis, treatment and follow-up, are recommended. The study objective was to evaluate primary care providers' (PCP) responses to SCPs developed for breast and colorectal cancer survivors in their practice and to determine whether PCP response to the SCPs varied according to characteristics of the practitioner and their practice. METHOD SCPs were created using the Journey Forward® Care Plan for breast and colorectal cancer patients in rural and urban settings. The SCP and a survey were sent to PCPs. PARTICIPANTS Primary care physicians. MAIN MEASURES Attitudes regarding survivorship care plans. RESULTS Thirty-nine (70.9% response rate) surveys were completed. Most felt the SCP was useful (90%), that it enhanced understanding (75%) and that detail was sufficient (>80%). However, 15% disagreed that the care plan helped them understand their role, a perception especially prevalent among PCPs in the rural setting. Among PCPs with ≤ 18 years in practice, 95% agreed that the SCP would improve communication with patients, contrasted with 60% of those with >21 years in practice. The most common barrier to providing follow-up care was limited access to survivors. CONCLUSIONS While SCPs appear to improve PCPs understanding of a cancer diagnosis and treatment, clear delineation of each provider's role in follow-up care is needed. Additional detail on which tests are needed and education on late and long term effects of cancer may improve coordination of care.
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Affiliation(s)
- Kim L Dittus
- Hematology/Oncology Division, University of Vermont, College of Medicine, Burlington, USA
| | - Brian L Sprague
- Department of Surgery and Office of Health Promotion Research, University of Vermont, Burlington, USA
| | - Claire M Pace
- Department of Radiation Oncology, Dartmouth Medical School, Lebanon, USA
| | - Dorothy A Dulko
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lori A Pollack
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, USA
| | - Nikki A Hawkins
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, USA
| | - Berta M Geller
- Family Medicine and Radiology Departments, University of Vermont, College of Medicine, Burlington, USA
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Allison KH, Reisch LM, Carney PA, Weaver DL, Schnitt SJ, O'Malley FP, Geller BM, Elmore JG. Understanding diagnostic variability in breast pathology: lessons learned from an expert consensus review panel. Histopathology 2014; 65:240-51. [PMID: 24511905 DOI: 10.1111/his.12387] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/03/2014] [Indexed: 11/30/2022]
Abstract
AIMS To gain a better understanding of the reasons for diagnostic variability, with the aim of reducing the phenomenon. METHODS AND RESULTS In preparation for a study on the interpretation of breast specimens (B-PATH), a panel of three experienced breast pathologists reviewed 336 cases to develop consensus reference diagnoses. After independent assessment, cases coded as diagnostically discordant were discussed at consensus meetings. By the use of qualitative data analysis techniques, transcripts of 16 h of consensus meetings for a subset of 201 cases were analysed. Diagnostic variability could be attributed to three overall root causes: (i) pathologist-related; (ii) diagnostic coding/study methodology-related; and (iii) specimen-related. Most pathologist-related root causes were attributable to professional differences in pathologists' opinions about whether the diagnostic criteria for a specific diagnosis were met, most frequently in cases of atypia. Diagnostic coding/study methodology-related root causes were primarily miscategorizations of descriptive text diagnoses, which led to the development of a standardized electronic diagnostic form (BPATH-Dx). Specimen-related root causes included artefacts, limited diagnostic material, and poor slide quality. After re-review and discussion, a consensus diagnosis could be assigned in all cases. CONCLUSIONS Diagnostic variability is related to multiple factors, but consensus conferences, standardized electronic reporting formats and comments on suboptimal specimen quality can be used to reduce diagnostic variability.
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Affiliation(s)
- Kimberly H Allison
- Department of Pathology, University of Washington Medical Center, Seattle, WA, USA
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Bolton KC, Mace JL, Vacek PM, Geller BM, Weaver DL, Sprague BL. Changes in the Breast Cancer Risk Distribution among Women Utilizing Screening Mammography in Vermont Between 2001 and 2012. Cancer Epidemiol Biomarkers Prev 2014. [DOI: 10.1158/1055-9965.epi-14-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
We previously reported a decline in overall breast cancer screening rates in Vermont following 2009. During this period, there has been debate regarding the role of patient context in decisions about when and how often to get screened, as well as increased interest in risk- based screening to optimize the balance between the potential benefits and harms of screening. The purpose of the current study was to evaluate whether the breast cancer risk distribution of the screened population in Vermont has changed during the observed decline in utilization rates. We examined the distribution of breast cancer risk among the screened population in Vermont from 2001 to 2012 using cross-sectional data from the statewide Vermont Breast Cancer Surveillance System. We employed the Breast Cancer Surveillance Consortium risk model to estimate each individual's risk of developing breast cancer within 5 years according to age, breast density, race/ethnicity, family history of breast cancer, and biopsy history. Among women ages 40 to 74 who received screening mammograms, the absolute number of visits dropped by 4,257, from 54,415 to 50,158 (−7.3%; 95% CI: −7.5, −7.1) between 2009 and 2012. Concurrently, the number of screened women who were estimated to be at low risk of developing breast cancer decreased by 4,240 (95% CI: 3,907, 4,573), representing the bulk of the overall decrease. There was no significant change in the aggregate number of women estimated to be at higher risk (−17 women; 95% CI: −350, 316). The outsized proportion of the decline attributed to women at low estimated risk held across younger and older age groups: among women ages 40 to 49, the absolute number screened dropped by 3,337, with 2,495 (95% CI: 2,389, 2,601) reflected by declines among women at low risk; among women ages 50 to 74, the absolute number screened dropped by only 920, however this value reflects a decrease of 1,763 (95% CI: 1,519, 2,007) for the low risk category, and gains totaling 843 (95% CI: 599, 1,087) among higher risk categories. We conclude that the observed decline in women screened in Vermont since 2009 is largely attributable to reductions in visits by women who are estimated to be at low risk of developing breast cancer, and that this trend generally holds across age groups.
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Sprague BL, Bolton KC, Mace JL, Herschorn SD, James TA, Vacek PM, Weaver DL, Geller BM. Registry-based study of trends in breast cancer screening mammography before and after the 2009 U.S. Preventive Services Task Force recommendations. Radiology 2014; 270:354-61. [PMID: 24072778 PMCID: PMC4118300 DOI: 10.1148/radiol.13131063] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine whether the 2009 U.S. Preventive Services Task Force (USPSTF) guidelines for breast cancer mammography screening were followed by changes in screening utilization in the state of Vermont. MATERIALS AND METHODS This retrospective study was HIPAA compliant and approved by the institutional review board, with waiver of informed consent. Trends in screening mammography utilization during 1997-2011 were examined among approximately 150,000 women aged 40 years and older in the state of Vermont using statewide mammography registry data. RESULTS The percentage of Vermont women aged 40 years and older screened in the past year declined from 45.3% in 2009% to 41.6% in 2011 (an absolute decrease of -3.7 percentage points; 95% confidence interval [CI]: -3.3, -4.1). The largest decline in utilization was among women aged 40-49 years (-4.8 percentage points; 95% CI: -4.1, -5.4), although substantial declines were also observed among women aged 50-74 years (-3.0 percentage points; 95% CI: -2.6, -3.5) and women aged 75 years and older (-3.1 percentage points; 95% CI: -2.3, -4.0). The percentage of women aged 50-74 years screened within the past 2 years declined by -3.4 percentage points (95% CI: -3.0, -3.9) from 65.4% in 2009 to 61.9% in 2011. CONCLUSION After years of increasing screening mammography utilization in Vermont, there was a decline in screening, which coincided with the release of the 2009 USPSTF recommendations. The age-specific patterns in utilization were generally consistent with the USPSTF recommendations, although there was also evidence that the percentage of women aged 50-74 years screened in the past 2 years declined since 2009.
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Affiliation(s)
- Brian L. Sprague
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
| | - Kenyon C. Bolton
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
| | - John L. Mace
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
| | - Sally D. Herschorn
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
| | - Ted A. James
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
| | - Pamela M. Vacek
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
| | - Donald L. Weaver
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
| | - Berta M. Geller
- From the Department of Surgery, University of Vermont, 1 S Prospect St, Burlington, VT 05401
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Wernli KJ, DeMartini WB, Ichikawa L, Lehman CD, Onega T, Kerlikowske K, Henderson LM, Geller BM, Hofmann M, Yankaskas BC. Patterns of breast magnetic resonance imaging use in community practice. JAMA Intern Med 2014; 174:125-32. [PMID: 24247555 PMCID: PMC3905972 DOI: 10.1001/jamainternmed.2013.11963] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Breast magnetic resonance imaging (MRI) is increasingly used for breast cancer screening, diagnostic evaluation, and surveillance. However, we lack data on national patterns of breast MRI use in community practice. OBJECTIVE To describe patterns of breast MRI use in US community practice during the period 2005 through 2009. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using data collected from 2005 through 2009 on breast MRI and mammography from 5 national Breast Cancer Surveillance Consortium registries. Data included 8931 breast MRI examinations and 1,288,924 screening mammograms from women aged 18 to 79 years. MAIN OUTCOMES AND MEASURES We calculated the rate of breast MRI examinations per 1000 women with breast imaging within the same year and described the clinical indications for the breast MRI examinations by year and age. We compared women screened with breast MRI to women screened with mammography alone for patient characteristics and lifetime breast cancer risk. RESULTS The overall rate of breast MRI from 2005 through 2009 nearly tripled from 4.2 to 11.5 examinations per 1000 women, with the most rapid increase from 2005 to 2007 (P = .02). The most common clinical indication was diagnostic evaluation (40.3%), followed by screening (31.7%). Compared with women who received screening mammography alone, women who underwent screening breast MRI were more likely to be younger than 50 years, white non-Hispanic, and nulliparous and to have a personal history of breast cancer, a family history of breast cancer, and extremely dense breast tissue (all P < .001). The proportion of women screened using breast MRI at high lifetime risk for breast cancer (>20%) increased during the study period from 9% in 2005 to 29% in 2009. CONCLUSIONS AND RELEVANCE Use of breast MRI for screening in high-risk women is increasing. However, our findings suggest that there is a need to improve appropriate use, including among women who may benefit from screening breast MRI.
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Affiliation(s)
| | - Wendy B DeMartini
- Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle
| | | | - Constance D Lehman
- Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle
| | - Tracy Onega
- Department of Community and Family Medicine, Norris Cotton Cancer Center, Dartmouth Medical School, Hanover, New Hampshire
| | - Karla Kerlikowske
- General Internal Medicine Section, Department of Veterans Affairs, San Francisco, California5Department of Medicine, University of California, San Francisco6Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington9Department of Radiology, University of Vermont, Burlington
| | - Mike Hofmann
- Department of Medicine, University of California, San Francisco
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Sprague BL, Dittus KL, Pace CM, Dulko D, Pollack LA, Hawkins NA, Geller BM. Patient satisfaction with breast and colorectal cancer survivorship care plans. Clin J Oncol Nurs 2013; 17:266-72. [PMID: 23722604 DOI: 10.1188/13.cjon.17-03ap] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Cancer survivors face several challenges following the completion of active treatment, including uncertainty about late effects of treatment and confusion about coordination of follow-up care. The authors evaluated patient satisfaction with personalized survivorship care plans designed to clarify those issues. The authors enrolled 48 patients with breast cancer and 10 patients with colorectal cancer who had completed treatment in the previous two months from an urban academic medical center and a rural community hospital. Patient satisfaction with the care plan was assessed by telephone interview. Overall, about 80% of patients were very or completely satisfied with the care plan, and 90% or more agreed that it was useful, it was easy to understand, and the length was appropriate. Most patients reported that the care plan was very or critically important to understanding an array of survivorship issues. However, only about half felt that it helped them better understand the roles of primary care providers and oncologists in survivorship care. The results provide evidence that patients with cancer find high value in personalized survivorship care plans, but the plans do not eliminate confusion regarding the coordination of follow-up care. Future efforts to improve care plans should focus on better descriptions of how survivorship care will be coordinated.
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Affiliation(s)
- Brian L Sprague
- Department of Surgery and the Office of Health Promotion Research, University of Vermont in Burlington, USA.
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Sowden M, Vacek P, Geller BM. The impact of cancer diagnosis on employment: is there a difference between rural and urban populations? J Cancer Surviv 2013; 8:213-7. [PMID: 24337871 DOI: 10.1007/s11764-013-0317-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 10/04/2013] [Indexed: 12/01/2022]
Abstract
PURPOSE To determine if living in a rural or urban area influences the impact of cancer diagnosis on employment. METHOD Surveys that asked about changes in employment status related to a cancer diagnosis or treatment were sent to 2,005 cancer survivors enrolled in the Vermont Cancer Survivor Surveillance Registry. Data on cancers were obtained from hospital cancer registries. Respondents indicating that they were working at the time of diagnosis were included in this study for a total of 1,155 participants. Associations between rural or urban residence and changes in employment were assessed by chi-square tests and logistic regression. RESULTS There were no statistically significant differences in the proportions of rural and urban survivors working fewer hours, experiencing a career change or unable to work. However, a larger proportion of rural than urban patients retired early after their diagnosis (11.1 vs. 7.2%, p = 0.031). There were also fewer rural patients that reported that they went on paid disability during cancer treatment (12.3 vs. 17.0%, p = 0.030). CONCLUSIONS While many patients will return to work after treatment for a cancer diagnosis, it appears that rural patients may be less likely to receive paid disability and more likely to retire early. It is possible that rural populations engage in more physically demanding jobs that they are unable to continue after their cancer treatment. Additionally the types of manual labor available in rural areas rarely offer disability benefits, increasing the impact of cancer diagnosis for this population. IMPLICATIONS FOR CANCER SURVIVORS A cancer diagnosis may have a greater impact on employment among rural residents. Cancer programs should recognize this disparity and enhance return to work and disability counseling in patients from rural areas.
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Carney PA, Bogart A, Sickles EA, Smith R, Buist DSM, Kerlikowske K, Onega T, Miglioretti DL, Rosenberg R, Yankaskas BC, Geller BM. Feasibility and acceptability of conducting a randomized clinical trial designed to improve interpretation of screening mammography. Acad Radiol 2013; 20:1389-98. [PMID: 24119351 PMCID: PMC4152937 DOI: 10.1016/j.acra.2013.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe recruitment, enrollment, and participation in a study of US radiologists invited to participate in a randomized controlled trial of two continuing medical education (CME) interventions designed to improve interpretation of screening mammography. METHODS We collected recruitment, consent, and intervention-completion information as part of a large study involving radiologists in California, Oregon, Washington, New Mexico, New Hampshire, North Carolina, and Vermont. Consenting radiologists were randomized to receive either a 1-day live, expert-led educational session; to receive a self-paced DVD with similar content; or to a control group (delayed intervention). The impact of the interventions was assessed using a preintervention-postintervention test set design. All activities were institutional review board approved and HIPAA compliant. RESULTS Of 403 eligible radiologists, 151 of 403 (37.5%) consented to participate in the trial and 119 of 151 (78.8%) completed the preintervention test set, leaving 119 available for randomization to one of the two intervention groups or to controls. Female radiologists were more likely than male radiologists to consent to and complete the study (P = .03). Consenting radiologists who completed all study activities were more likely to have been interpreting mammography for 10 years or less compared to radiologists who consented and did not complete all study activities or did not consent at all. The live intervention group was more likely to report their intent to change their clinical practice as a result of the intervention compared to those who received the DVD (50% versus 17.6%, P = .02). The majority of participants in both interventions groups felt the interventions were a useful way to receive CME mammography credits. CONCLUSIONS Community radiologists found interactive interventions designed to improve interpretative mammography performance acceptable and useful for clinical practice. This suggests CME credits for radiologists should, in part, be for examining practice skills.
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Affiliation(s)
- Patricia A Carney
- Departments of Family Medicine and Public Health and Preventive Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: FM, Portland, OR 97239.
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Allison KH, Abraham LA, Weaver DL, Tosteson ANA, Onega T, Geller BM, Kerlikowske K, Carney PA, Ichikawa LE, Buist DSM, Elmore JG. Tissue sampling frequency and breast pathology diagnoses following mammography: Time trends and age group analysis from the Breast Cancer Surveillance Consortium (BCSC). J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
559 Background: Pathology diagnoses in a well-characterized population of women can be used to identify tissue sampling and diagnosis trends following mammography. Methods: Screening and diagnostic mammography, patient characteristics, and pathology reports from the BCSC performed from 1996-2008 were identified. Diagnosis was based on the most severe pathology interpretation in the same breast within 60 days of a post-mammogram tissue sample. Age, mammogram year and type, breast density, and family history of breast cancer were evaluated for associations with tissue sampling and most severe pathology diagnosis. Results: 4,022,506 mammograms (88.5% screening; 11.5% diagnostic) were performed in 1,288,886 women; 76,567 (1.9%) were followed by tissue sampling (1.2% screening; 7.1% diagnostic). Tissue sampling frequency following diagnostic mammography increased over time in women over 50 but remained stable following screening mammography. The frequency of invasive cancer increased with age and was more common following a diagnostic (29.3%) vs screening (19.8%) mammogram; the frequency of high risk lesions (ADH; lobular neoplasia) was highest in women aged 50-59. For tissue sampling following screening mammograms, the frequency of DCIS increased over time while benign diagnoses decreased. No significant time trends were noted for diagnoses associated with diagnostic mammograms. Women aged 40-59 with dense breasts and a tissue sampling following screening mammogram had a significantly higher frequency of DCIS (40-49: 4.8% vs 3.2%, P< 0.001; 50-59: 7.0% vs 5.7%, P=0.007). Women aged 40-59 with > 1first degree relative with breast cancer vs none that had a tissue sampling following screening mammogram had a significantly higher frequency of invasive cancer (40-49: 11.4% vs 9.4%, p=0.008; 50-59: 19.8% vs 18.2%, p =0.086) and DCIS (40-49: 6.2% vs 4.0%, p< 0.001; 50-59: 8.2% vs 6.2%, p< 0.001). Conclusions: There was an increase in DCIS and a decrease in benign diagnoses in tissues samples after screening mammography over time. No trends were seen following diagnostic mammography. DCIS was also more frequent in women with dense breasts.
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Affiliation(s)
| | | | - Donald L. Weaver
- National Surgical Adjuvant Breast and Bowel Project; Department of Pathology, University of Vermont College of Medicine, Burlington, VT
| | | | - Tracy Onega
- Dartmouth Medical School/Norris Cotton Cancer Center, Lebanon, NH
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Flynn BS, Worden JK, Secker-Walker RH, Badger GJ, Geller BM. Cigarette Smoking Prevention Effects of Mass Media and School Interventions Targeted to Gender and Age Groups. ACTA ACUST UNITED AC 2013. [DOI: 10.1080/10556699.1995.10603147] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Brian S. Flynn
- a Office of Health Promotion Research and the Vermont Cancer Center , USA
- b Department of Family Practice , College of Medicine, University of Vermont , USA
| | - John K. Worden
- a Office of Health Promotion Research and the Vermont Cancer Center , USA
- b Department of Family Practice , College of Medicine, University of Vermont , USA
| | - Roger H. Secker-Walker
- a Office of Health Promotion Research and the Vermont Cancer Center , USA
- b Department of Family Practice , College of Medicine, University of Vermont , USA
| | - Gary J. Badger
- c Medical Biostatistics Unit , College of Medicine, University of Vermont , USA
| | - Berta M. Geller
- a Office of Health Promotion Research and the Vermont Cancer Center , USA
- b Department of Family Practice , College of Medicine, University of Vermont , USA
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Hofvind S, Geller BM, Skelly J, Vacek PM. Sensitivity and specificity of mammographic screening as practised in Vermont and Norway. Br J Radiol 2012; 85:e1226-32. [PMID: 22993383 PMCID: PMC3611728 DOI: 10.1259/bjr/15168178] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 03/13/2012] [Accepted: 04/16/2012] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to examine the sensitivity and specificity of screening mammography as performed in Vermont, USA, and Norway. METHODS Incident screening data from 1997 to 2003 for female patients aged 50-69 years from the Vermont Breast Cancer Surveillance System (116 996 subsequent screening examinations) and the Norwegian Breast Cancer Screening Program (360 872 subsequent screening examinations) were compared. Sensitivity and specificity estimates for the initial (based on screening mammogram only) and final (screening mammogram plus any further diagnostic imaging) interpretations were directly adjusted for age using 5-year age intervals for the combined Vermont and Norway population, and computed for 1 and 2 years of follow-up, which ended at the time of the next screening mammogram. RESULTS For the 1-year follow-up, sensitivities for initial assessments were 82.0%, 88.2% and 92.5% for 1-, 2- and >2-year screening intervals, respectively, in Vermont (p=0.022). For final assessments, the values were 73.6%, 83.3% and 81.2% (p=0.047), respectively. For Norway, sensitivities for initial assessments were 91.0% and 91.3% (p=0.529) for 2- and >2-year intervals, and 90.7% and 91.3%, respectively, for final assessments (p=0.630). Specificity was lower in Vermont than in Norway for each screening interval and for all screening intervals combined, for both initial (90.6% vs 97.8% for all intervals; p<0.001) and final (98.8% vs 99.5% for all intervals; p<0.001) assessments. CONCLUSION Our study showed higher sensitivity and specificity in a biennial screening programme with an independent double reading than in a predominantly annual screening program with a single reading. ADVANCES IN KNOWLEDGE This study demonstrates that higher recall rates and lower specificity are not always associated with higher sensitivity of screening mammography. Differences in the screening processes in Norway and Vermont suggest potential areas for improvement in the latter.
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Affiliation(s)
- S Hofvind
- Cancer Registry of Norway, Oslo, Norway.
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Carney PA, Abraham L, Cook A, Feig SA, Sickles EA, Miglioretti DL, Geller BM, Yankaskas BC, Elmore JG. Impact of an educational intervention designed to reduce unnecessary recall during screening mammography. Acad Radiol 2012; 19:1114-20. [PMID: 22727623 DOI: 10.1016/j.acra.2012.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 04/27/2012] [Accepted: 05/03/2012] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to describe the impact of a tailored Web-based educational program designed to reduce excessive screening mammography recall. MATERIALS AND METHODS Radiologists enrolled in one of four mammography registries in the United States were invited to take part and were randomly assigned to receive the intervention or to serve as controls. The controls were offered the intervention at the end of the study, and data collection included an assessment of their clinical practice as well. The intervention provided each radiologist with individual audit data for his or her sensitivity, specificity, recall rate, positive predictive value, and cancer detection rate compared to national benchmarks and peer comparisons for the same measures; profiled breast cancer risk in each radiologist's respective patient populations to illustrate how low breast cancer risk is in population-based settings; and evaluated the possible impact of medical malpractice concerns on recall rates. Participants' recall rates from actual practice were evaluated for three time periods: the 9 months before the intervention was delivered to the intervention group (baseline period), the 9 months between the intervention and control groups (T1), and the 9 months after completion of the intervention by the controls (T2). Logistic regression models examining the probability that a mammogram was recalled included indication of intervention versus control and time period (baseline, T1, and T2). Interactions between the groups and time period were also included to determine if the association between time period and the probability of a positive result differed across groups. RESULTS Thirty-one radiologists who completed the continuing medical education intervention were included in the adjusted model comparing radiologists in the intervention group (n = 22) to radiologists who completed the intervention in the control group (n = 9). At T1, the intervention group had 12% higher odds of positive mammographic results compared to the controls, after controlling for baseline (odds ratio, 1.12; 95% confidence interval, 1.00-1.27; P = .0569). At T2, a similar association was found, but it was not statistically significant (odds ratio, 1.10; 95% confidence interval, 0.96 to 1.25). No associations were found among radiologists in the control group when comparing those who completed the continuing medical education intervention (n = 9) to those who did not (n = 10). In addition, no associations were found between time period and recall rate among radiologists who set realistic goals. CONCLUSIONS This study resulted in a null effect, which may indicate that a single 1-hour intervention is not adequate to change excessive recall among radiologists who undertook the intervention being tested.
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Affiliation(s)
- Patricia A Carney
- Department of Family Medicine and Public Health and Preventive Medicine, Oregon Health & Science University, Portland, 97239-3098, USA.
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Spayne MC, Gard CC, Skelly J, Miglioretti DL, Vacek PM, Geller BM. Reproducibility of BI-RADS breast density measures among community radiologists: a prospective cohort study. Breast J 2012; 18:326-33. [PMID: 22607064 PMCID: PMC3660069 DOI: 10.1111/j.1524-4741.2012.01250.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Using data from the Vermont Breast Cancer Surveillance System (VBCSS), we studied the reproducibility of Breast Imaging Reporting and Data System (BI-RADS) breast density among community radiologists interpreting mammograms in a cohort of 11,755 postmenopausal women. Radiologists interpreting two or more film-screen screening or bilateral diagnostic mammograms for the same woman within a 3- to 24-month period during 1996-2006 were eligible. We observed moderate-to-substantial overall intra-rater agreement for use of BI-RADS breast density in clinical practice, with an overall intra-radiologist percent agreement of 77.2% (95% confidence interval (CI), 74.5-79.5%), an overall simple kappa of 0.58 (95% CI, 0.55-0.61), and an overall weighted kappa of 0.70 (95% CI, 0.68-0.73). Agreement exhibited by individual radiologists varied widely, with intra-radiologist percent agreement ranging from 62.1% to 87.4% and simple kappa ranging from 0.19 to 0.69 across individual radiologists. Our findings underscore the need for additional evaluation of the BI-RADS breast density categorization system in clinical practice.
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Affiliation(s)
| | - Charlotte C. Gard
- Biostatistics Unit, Group Health Research Institute, Group Health Cooperative, Seattle, WA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA
| | - Joan Skelly
- Medical Biostatistics, University of Vermont, Burlington, VT
| | - Diana L. Miglioretti
- Biostatistics Unit, Group Health Research Institute, Group Health Cooperative, Seattle, WA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA
| | - Pamela M. Vacek
- Medical Biostatistics, University of Vermont, Burlington, VT
| | - Berta M. Geller
- Departments of Family Medicine and Radiology, University of Vermont, Burlington, VT
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Yasmeen S, Hubbard RA, Romano PS, Zhu W, Geller BM, Onega T, Yankaskas BC, Miglioretti DL, Kerlikowske K. Risk of advanced-stage breast cancer among older women with comorbidities. Cancer Epidemiol Biomarkers Prev 2012; 21:1510-9. [PMID: 22744339 DOI: 10.1158/1055-9965.epi-12-0320] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Comorbidities have been suggested influencing mammography use and breast cancer stage at diagnosis. We compared mammography use, and overall and advanced-stage breast cancer rates, among female Medicare beneficiaries with different levels of comorbidity. METHODS We used linked Breast Cancer Surveillance Consortium (BCSC) and Medicare claims data from 1998 through 2006 to ascertain comorbidities among 149,045 female Medicare beneficiaries ages 67 and older who had mammography. We defined comorbidities as either "unstable" (life-threatening or difficult to control) or "stable" (age-related with potential to affect daily activity) on the basis of claims within 2 years before each mammogram. RESULTS Having undergone two mammograms within 30 months was more common in women with stable comorbidities (86%) than in those with unstable (80.3%) or no (80.9%) comorbidities. Overall rates of advanced-stage breast cancer were lower among women with no comorbidities [0.5 per 1,000 mammograms, 95% confidence interval (CI), 0.3-0.8] than among those with stable comorbidities (0.8; 95% CI, 0.7-0.9; P = 0.065 compared with no comorbidities) or unstable comorbidities (1.1; 95% CI, 0.9-1.3; P = 0.002 compared with no comorbidities). Among women having undergone two mammograms within 4 to 18 months, those with unstable and stable comorbidities had significantly higher advanced cancer rates than those with no comorbidities (P = 0.004 and P = 0.03, respectively). CONCLUSIONS Comorbidities were associated with more frequent use of mammography but also higher risk of advanced-stage disease at diagnosis among the subset of women who had the most frequent use of mammography. IMPACT Future studies need to examine whether specific comorbidities affect clinical progression of breast cancer.
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Affiliation(s)
- Shagufta Yasmeen
- University of California Davis School of Medicine, Sacramento, CA 95817, USA.
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Jackson SL, Cook AJ, Miglioretti DL, Carney PA, Geller BM, Onega T, Rosenberg RD, Brenner RJ, Elmore JG. Are radiologists' goals for mammography accuracy consistent with published recommendations? Acad Radiol 2012; 19:289-95. [PMID: 22130089 DOI: 10.1016/j.acra.2011.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 10/03/2011] [Accepted: 10/07/2011] [Indexed: 10/14/2022]
Abstract
RATIONALE AND OBJECTIVES Mammography quality assurance programs have been in place for more than a decade. We studied radiologists' self-reported performance goals for accuracy in screening mammography and compared them to published recommendations. MATERIALS AND METHODS A mailed survey of radiologists at mammography registries in seven states within the Breast Cancer Surveillance Consortium (BCSC) assessed radiologists' performance goals for interpreting screening mammograms. Self-reported goals were compared to published American College of Radiology (ACR) recommended desirable ranges for recall rate, false-positive rate, positive predictive value of biopsy recommendation (PPV2), and cancer detection rate. Radiologists' goals for interpretive accuracy within desirable range were evaluated for associations with their demographic characteristics, clinical experience, and receipt of audit reports. RESULTS The survey response rate was 71% (257 of 364 radiologists). The percentage of radiologists reporting goals within desirable ranges was 79% for recall rate, 22% for false-positive rate, 39% for PPV2, and 61% for cancer detection rate. The range of reported goals was 0%-100% for false-positive rate and PPV2. Primary academic affiliation, receiving more hours of breast imaging continuing medical education, and receiving audit reports at least annually were associated with desirable PPV2 goals. Radiologists reporting desirable cancer detection rate goals were more likely to have interpreted mammograms for 10 or more years, and >1000 mammograms per year. CONCLUSION Many radiologists report goals for their accuracy when interpreting screening mammograms that fall outside of published desirable benchmarks, particularly for false-positive rate and PPV2, indicating an opportunity for education.
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Carney PA, Cook AJ, Miglioretti DL, Feig SA, Bowles EA, Geller BM, Kerlikowske K, Kettler M, Onega T, Elmore JG. Use of clinical history affects accuracy of interpretive performance of screening mammography. J Clin Epidemiol 2012; 65:219-30. [PMID: 22000816 PMCID: PMC3253253 DOI: 10.1016/j.jclinepi.2011.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 06/15/2011] [Accepted: 06/18/2011] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To examine how use of clinical history affects radiologist's interpretation of screening mammography. STUDY DESIGN AND SETTING Using a self-administered survey and actual interpretive performance, we examined associations between use of clinical history and sensitivity, false-positive rate, recall rate, and positive predictive value, after adjusting for relevant covariates using conditional logistic regression. RESULTS Of the 216 radiologists surveyed (63.4%), most radiologists reported usually or always using clinical history when interpreting screening mammography. Compared with radiologists who rarely use clinical history, radiologists who usually or always use it had a higher false-positive rate with younger women (10.7 vs. 9.7), denser breast tissue (10.1 for heterogeneously dense to 10.9 for extremely dense vs. 8.9 for fatty tissue), or longer screening intervals (> prior 5 years) (12.5 vs. 10.5). Effect of current hormone therapy (HT) use on false-positive rate was weaker among radiologists who use clinical history compared with those who did not (P=0.01), resulting in fewer false-positive examinations and a nonsignificant lower sensitivity (79.2 vs. 85.2) among HT users. CONCLUSION Interpretive performance appears to be influenced by patient age, breast density, screening interval, and HT use. This influence does not always result in improved interpretive performance.
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Affiliation(s)
- Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR 97239-3098, USA.
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Abstract
Little is known about the late and long term effects of having survived cancer and its treatments. A cancer survivor registry with a representative longitudinal cohort of survivors from all types of cancers would facilitate the study of these effects. A group of researchers, cancer survivors and cancer registrars used hospital cancer registries to identify cancer survivors diagnosed from 1990 through 2006. All eligible cancer survivors were invited to participate in a cancer survivor registry. We describe our methods for engaging the community, who responded to the invitation and who agreed to participate. We used Chi square tests with a significance level of .05 to assess associations with response and participation rates. We used logistic regression to examine associations with participation after adjustment for the effect of age. Logistic regression was also used to assess the independent effects of those variables that were significantly associated with participation after adjustment for age. Of the 6031 eligible survivors, 55% responded to the invitation. Of those who responded 61% agreed to participate in the cancer survivor registry for an overall participation rate of 33%. Rural residence, less education, full time employment, and lower income were independently related to not participating, but marital status was not associated with participation after adjustment for these variables. It is very difficult to recruit a representative sample of cancer survivors to participate in a cancer survivor registry. More research on how to engage the underserved population (rural residents, less education and lower income) is warranted.
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Affiliation(s)
- Berta M Geller
- Departments of Family Medicine and Radiology, University of Vermont, Burlington, VT 05401-3444, USA.
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Haneuse S, Buist DSM, Miglioretti DL, Anderson ML, Carney PA, Onega T, Geller BM, Kerlikowske K, Rosenberg RD, Yankaskas BC, Elmore JG, Taplin SH, Smith RA, Sickles EA. Mammographic interpretive volume and diagnostic mammogram interpretation performance in community practice. Radiology 2011; 262:69-79. [PMID: 22106351 DOI: 10.1148/radiol.11111026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the association between radiologist interpretive volume and diagnostic mammography performance in community-based settings. MATERIALS AND METHODS This study received institutional review board approval and was HIPAA compliant. A total of 117,136 diagnostic mammograms that were interpreted by 107 radiologists between 2002 and 2006 in the Breast Cancer Surveillance Consortium were included. Logistic regression analysis was used to estimate the adjusted effect on sensitivity and the rates of false-positive findings and cancer detection of four volume measures: annual diagnostic volume, screening volume, total volume, and diagnostic focus (percentage of total volume that is diagnostic). Analyses were stratified by the indication for imaging: additional imaging after screening mammography or evaluation of a breast concern or problem. RESULTS Diagnostic volume was associated with sensitivity; the odds of a true-positive finding rose until a diagnostic volume of 1000 mammograms was reached; thereafter, they either leveled off (P < .001 for additional imaging) or decreased (P = .049 for breast concerns or problems) with further volume increases. Diagnostic focus was associated with false-positive rate; the odds of a false-positive finding increased until a diagnostic focus of 20% was reached and decreased thereafter (P < .024 for additional imaging and P < .001 for breast concerns or problems with no self-reported lump). Neither total volume nor screening volume was consistently associated with diagnostic performance. CONCLUSION Interpretive volume and diagnostic performance have complex multifaceted relationships. Our results suggest that diagnostic interpretive volume is a key determinant in the development of thresholds for considering a diagnostic mammogram to be abnormal. Current volume regulations do not distinguish between screening and diagnostic mammography, and doing so would likely be challenging.
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Affiliation(s)
- Sebastien Haneuse
- Department of Biostatistics, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
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Kerlikowske K, Hubbard RA, Miglioretti DL, Geller BM, Yankaskas BC, Lehman CD, Taplin SH, Sickles EA. Comparative effectiveness of digital versus film-screen mammography in community practice in the United States: a cohort study. Ann Intern Med 2011; 155:493-502. [PMID: 22007043 PMCID: PMC3726800 DOI: 10.7326/0003-4819-155-8-201110180-00005] [Citation(s) in RCA: 191] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Few studies have examined the comparative effectiveness of digital versus film-screen mammography in U.S. community practice. OBJECTIVE To determine whether the interpretive performance of digital and film-screen mammography differs. DESIGN Prospective cohort study. SETTING Mammography facilities in the Breast Cancer Surveillance Consortium. PARTICIPANTS 329,261 women aged 40 to 79 years underwent 869 286 mammograms (231 034 digital; 638 252 film-screen). MEASUREMENTS Invasive cancer or ductal carcinoma in situ diagnosed within 12 months of a digital or film-screen examination and calculation of mammography sensitivity, specificity, cancer detection rates, and tumor outcomes. RESULTS Overall, cancer detection rates and tumor characteristics were similar for digital and film-screen mammography, but the sensitivity and specificity of each modality varied by age, tumor characteristics, breast density, and menopausal status. Compared with film-screen mammography, the sensitivity of digital mammography was significantly higher for women aged 60 to 69 years (89.9% vs. 83.0%; P = 0.014) and those with estrogen receptor-negative cancer (78.5% vs. 65.8%; P = 0.016); borderline significantly higher for women aged 40 to 49 years (82.4% vs. 75.6%; P = 0.071), those with extremely dense breasts (83.6% vs. 68.1%; P = 0.051), and pre- or perimenopausal women (87.1% vs. 81.7%; P = 0.057); and borderline significantly lower for women aged 50 to 59 years (80.5% vs. 85.1%; P = 0.097). The specificity of digital and film-screen mammography was similar by decade of age, except for women aged 40 to 49 years (88.0% vs. 89.7%; P < 0.001). LIMITATION Statistical power for subgroup analyses was limited. CONCLUSION Overall, cancer detection with digital or film-screen mammography is similar in U.S. women aged 50 to 79 years undergoing screening mammography. Women aged 40 to 49 years are more likely to have extremely dense breasts and estrogen receptor-negative tumors; if they are offered mammography screening, they may choose to undergo digital mammography to optimize cancer detection. PRIMARY FUNDING SOURCE National Cancer Institute.
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Rosenberg RD, Haneuse SJPA, Geller BM, Buist DSM, Miglioretti DL, Brenner RJ, Smith-Bindman R, Taplin SH. Timeliness of follow-up after abnormal screening mammogram: variability of facilities. Radiology 2011; 261:404-13. [PMID: 21900620 DOI: 10.1148/radiol.11102472] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To describe the timeliness of follow-up care in community-based settings among women who receive a recommendation for immediate follow-up during the screening mammography process and how follow-up timeliness varies according to facility and facility-level characteristics. MATERIALS AND METHODS This was an institutional review board-approved and HIPAA-compliant study. Screening mammograms obtained from 1996 to 2007 in women 40-80 years old in the Breast Cancer Surveillance Consortium were examined. Inclusion criteria were a recommendation for immediate follow-up at screening, or subsequent imaging, and observed follow-up within 180 days of the recommendation. Recommendations for additional imaging (AI) and biopsy or surgical consultation (BSC) were analyzed separately. The distribution of time to follow-up care was estimated by using the Kaplan-Meier estimator. RESULTS Data were available on 214,897 AI recommendations from 118 facilities and 35,622 BSC recommendations from 101 facilities. The median time to subsequent follow-up care after recommendation was 14 days for AI and 16 days for BSC. Approximately 90% of AI follow-up and 81% of BSC follow-up occurred within 30 days. Facilities with higher recall rates tended to have longer AI follow-up times (P < .001). Over the study period, BSC follow-up rates at 15 and 30 days improved (P < .001). Follow-up times varied substantially across facilities. Timely follow-up was associated with larger volumes of the recommended procedures but not notably associated with facility type nor observed facility-level characteristics. CONCLUSION Most patients with follow-up returned within 3 weeks of the recommendation.
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Affiliation(s)
- Robert D Rosenberg
- Department of Radiology, University of New Mexico-HSC, 1 University of New Mexico, HSC 10 5530, Albuquerque, NM 87131-0001, USA.
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Fenton JJ, Abraham L, Taplin SH, Geller BM, Carney PA, D'Orsi C, Elmore JG, Barlow WE. Effectiveness of computer-aided detection in community mammography practice. J Natl Cancer Inst 2011; 103:1152-61. [PMID: 21795668 DOI: 10.1093/jnci/djr206] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Computer-aided detection (CAD) is applied during screening mammography for millions of US women annually, although it is uncertain whether CAD improves breast cancer detection when used by community radiologists. METHODS We investigated the association between CAD use during film-screen screening mammography and specificity, sensitivity, positive predictive value, cancer detection rates, and prognostic characteristics of breast cancers (stage, size, and node involvement). Records from 684 956 women who received more than 1.6 million film-screen mammograms at Breast Cancer Surveillance Consortium facilities in seven states in the United States from 1998 to 2006 were analyzed. We used random-effects logistic regression to estimate associations between CAD and specificity (true-negative examinations among women without breast cancer), sensitivity (true-positive examinations among women with breast cancer diagnosed within 1 year of mammography), and positive predictive value (breast cancer diagnosed after positive mammograms) while adjusting for mammography registry, patient age, time since previous mammography, breast density, use of hormone replacement therapy, and year of examination (1998-2002 vs 2003-2006). All statistical tests were two-sided. RESULTS Of 90 total facilities, 25 (27.8%) adopted CAD and used it for an average of 27.5 study months. In adjusted analyses, CAD use was associated with statistically significantly lower specificity (OR = 0.87, 95% confidence interval [CI] = 0.85 to 0.89, P < .001) and positive predictive value (OR = 0.89, 95% CI = 0.80 to 0.99, P = .03). A non-statistically significant increase in overall sensitivity with CAD (OR = 1.06, 95% CI = 0.84 to 1.33, P = .62) was attributed to increased sensitivity for ductal carcinoma in situ (OR = 1.55, 95% CI = 0.83 to 2.91; P = .17), although sensitivity for invasive cancer was similar with or without CAD (OR = 0.96, 95% CI = 0.75 to 1.24; P = .77). CAD was not associated with higher breast cancer detection rates or more favorable stage, size, or lymph node status of invasive breast cancer. CONCLUSION CAD use during film-screen screening mammography in the United States is associated with decreased specificity but not with improvement in the detection rate or prognostic characteristics of invasive breast cancer.
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Affiliation(s)
- Joshua J Fenton
- Department of Family and Community Medicine and Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA 95817, USA.
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Carney PA, Bowles EJA, Sickles EA, Geller BM, Feig SA, Jackson S, Brown D, Cook A, Yankaskas BC, Miglioretti DL, Elmore JG. Using a tailored web-based intervention to set goals to reduce unnecessary recall. Acad Radiol 2011; 18:495-503. [PMID: 21251856 PMCID: PMC3065970 DOI: 10.1016/j.acra.2010.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 11/29/2010] [Accepted: 11/29/2010] [Indexed: 11/21/2022]
Abstract
RATIONALE AND OBJECTIVES To examine whether an intervention strategy consisting of a tailored web-based intervention, which provides individualized audit data with peer comparisons and other data that can affect recall, can assist radiologists in setting goals for reducing unnecessary recall. MATERIALS AND METHODS In a multisite randomized controlled study, we used a tailored web-based intervention to assess radiologists' ability to set goals to improve interpretive performance. The intervention provided peer comparison audit data, profiled breast cancer risk in each radiologist's respective patient populations, and evaluated the possible impact of medical malpractice concerns. We calculated the percentage of radiologists who would consider changing their recall rates, and examined the specific goals they set to reduce recall rates. We describe characteristics of radiologists who developed realistic goals to reduce their recall rates, and their reactions to the importance of patient risk factors and medical malpractice concerns. RESULTS Forty-one of 46 radiologists (89.1%) who started the intervention completed it. Thirty-one (72.1%) indicated they would like to change their recall rates and 30 (69.8%) entered a text response about changing their rates. Sixteen of the 30 (53.3%) radiologists who included a text response set realistic goals that would likely result in reducing unnecessary recall. The actual recall rates of those who set realistic goals were not statistically different from those who did not (13.8% vs. 15.1%, respectively). The majority of selected goals involved re-reviewing cases initially interpreted as Breast Imaging Reporting and Data System category 0. More than half of radiologists who commented on the influence of patient risk (56.3%) indicated that radiologists planned to pay more attention to risk factors, and 100% of participants commented on concerns radiologists have about malpractice with the primary concern (37.5%) being fear of lawsuits. CONCLUSIONS Interventions designed to reduce unnecessary recall can succeed in assisting radiologists to develop goals that may ultimately reduce unnecessary recall.
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Affiliation(s)
- Patricia A Carney
- Departments of Family Medicine and Public Health and Preventive Medicine, Oregon Health & Science University, Portland, 97239-3098, USA.
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Carney PA, Geller BM, Sickles EA, Miglioretti DL, Aiello Bowles EJ, Abraham L, Feig SA, Brown D, Cook AJ, Yankaskas BC, Elmore JG. Feasibility and satisfaction with a tailored web-based audit intervention for recalibrating radiologists' thresholds for conducting additional work-up. Acad Radiol 2011; 18:369-76. [PMID: 21193335 PMCID: PMC3034778 DOI: 10.1016/j.acra.2010.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 10/18/2010] [Accepted: 10/20/2010] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES To examine the feasibility of and satisfaction with a tailored web-based intervention designed to decrease radiologists' recommendation of inappropriate additional work-up after a screening mammogram. MATERIALS AND METHODS We developed a web-based educational intervention designed to reduce inappropriate recall. Radiologists were randomly assigned to participate in an early intervention group or a late (control) intervention group, the latter of which served as a control for a 9-month follow-up period, after which they were invited to participate in the intervention. Intervention content was derived from our prior research and included three modules: 1) an introduction to audit statistics for mammography performance; 2) a review of data showing radiologists' inflated perceptions of medical malpractice risks related to breast imaging, and 3) a review of data on breast cancer risk among women seen in their practices. Embedded within the intervention were individualized audit data for each participating radiologists obtained from the national Breast Cancer Surveillance Consortium. RESULTS Seventy-four radiologists (37.8%; 74/196) consented to the intervention, which was completed by 67.5% (27/40) of those randomized to the early intervention group and 41.2% (14/34) of those randomized to the late (control) group. Thus, a total of 41 (55%) completed the intervention. On average, three log-ins were used to complete the program (range 1-14), which took approximately 1 hour. Ninety-five percent found the program moderately to very helpful in understanding how to calculate basic performance measures. Ninety-three percent found viewing their own performance measures moderately to very helpful, and 83% reported it being moderately to very important to learn that the breast cancer risk in their screening population program was lower than perceived. The percentage of radiologists who reported that the risk of medical malpractice influences their recall rates dropped from 36.3% preintervention to 17.8% after intervention with a similar drop in perceived influence of malpractice risk on their recommendations for breast biopsy (36.4 to 17.3%). More than 75% of radiologists answered the postintervention knowledge questions correctly, and the percent of time spent in breast imaging did not appear to influence responses. The majority (>92%) of participants correctly responded that the target recall rate in the United States is 9%. The mean self-reported recall rates were 13.0 for radiologists spending <40% time in breast imaging and 14.9% for those spending >40% time spent in breast imaging, which was highly correlated with their actual recall rates (0.991; P < .001). CONCLUSIONS Radiologists who begin an internet-based tailored intervention designed to help reduce unnecessary recall will likely complete it, although only 55% who consented to the study actually undertook the intervention. Participants found the program useful in helping them understand why their recall rates may be elevated.
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Affiliation(s)
- Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098, USA.
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Houssami N, Abraham LA, Miglioretti DL, Sickles EA, Kerlikowske K, Buist DSM, Geller BM, Muss HB, Irwig L. Accuracy and outcomes of screening mammography in women with a personal history of early-stage breast cancer. JAMA 2011; 305:790-9. [PMID: 21343578 PMCID: PMC3799940 DOI: 10.1001/jama.2011.188] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Women with a personal history of breast cancer (PHBC) are at risk of developing another breast cancer and are recommended for screening mammography. Few high-quality data exist on screening performance in PHBC women. OBJECTIVE To examine the accuracy and outcomes of mammography screening in PHBC women relative to screening of similar women without PHBC. DESIGN AND SETTING Cohort of PHBC women, mammogram matched to non-PHBC women, screened through facilities (1996-2007) affiliated with the Breast Cancer Surveillance Consortium. PARTICIPANTS There were 58,870 screening mammograms in 19,078 women with a history of early-stage (in situ or stage I-II invasive) breast cancer and 58,870 matched (breast density, age group, mammography year, and registry) screening mammograms in 55,315 non-PHBC women. MAIN OUTCOME MEASURES Mammography accuracy based on final assessment, cancer detection rate, interval cancer rate, and stage at diagnosis. RESULTS Within 1 year after screening, 655 cancers were observed in PHBC women (499 invasive, 156 in situ) and 342 cancers (285 invasive, 57 in situ) in non-PHBC women. Screening accuracy and outcomes in PHBC relative to non-PHBC women were cancer rates of 10.5 per 1000 screens (95% CI, 9.7-11.3) vs 5.8 per 1000 screens (95% CI, 5.2-6.4), cancer detection rate of 6.8 per 1000 screens (95% CI, 6.2-7.5) vs 4.4 per 1000 screens (95% CI, 3.9-5.0), interval cancer rate of 3.6 per 1000 screens (95% CI, 3.2-4.1) vs 1.4 per 1000 screens (95% CI, 1.1-1.7), sensitivity 65.4% (95% CI, 61.5%-69.0%) vs 76.5% (95% CI, 71.7%-80.7%), specificity 98.3% (95% CI, 98.2%-98.4%) vs 99.0% (95% CI, 98.9%-99.1%), abnormal mammogram results in 2.3% (95% CI, 2.2%-2.5%) vs 1.4% (95% CI, 1.3%-1.5%) (all comparisons P < .001). Screening sensitivity in PHBC women was higher for detection of in situ cancer (78.7%; 95% CI, 71.4%-84.5%) than invasive cancer (61.1%; 95% CI, 56.6%-65.4%), P < .001; lower in the initial 5 years (60.2%; 95% CI, 54.7%-65.5%) than after 5 years from first cancer (70.8%; 95% CI, 65.4%-75.6%), P = .006; and was similar for detection of ipsilateral cancer (66.3%; 95% CI, 60.3%-71.8%) and contralateral cancer (66.1%; 95% CI, 60.9%-70.9%), P = .96. Screen-detected and interval cancers in women with and without PHBC were predominantly early stage. CONCLUSION Mammography screening in PHBC women detects early-stage second breast cancers but has lower sensitivity and higher interval cancer rate, despite more evaluation and higher underlying cancer rate, relative to that in non-PHBC women.
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Affiliation(s)
- Nehmat Houssami
- Screening and Test Evaluation Program, School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia.
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Buist DSM, Anderson ML, Haneuse SJPA, Sickles EA, Smith RA, Carney PA, Taplin SH, Rosenberg RD, Geller BM, Onega TL, Monsees BS, Bassett LW, Yankaskas BC, Elmore JG, Kerlikowske K, Miglioretti DL. Influence of annual interpretive volume on screening mammography performance in the United States. Radiology 2011; 259:72-84. [PMID: 21343539 DOI: 10.1148/radiol.10101698] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine whether U.S. radiologists' interpretive volume affects their screening mammography performance. MATERIALS AND METHODS Annual interpretive volume measures (total, screening, diagnostic, and screening focus [ratio of screening to diagnostic mammograms]) were collected for 120 radiologists in the Breast Cancer Surveillance Consortium (BCSC) who interpreted 783 965 screening mammograms from 2002 to 2006. Volume measures in 1 year were examined by using multivariate logistic regression relative to screening sensitivity, false-positive rates, and cancer detection rate the next year. BCSC registries and the Statistical Coordinating Center received institutional review board approval for active or passive consenting processes and a Federal Certificate of Confidentiality and other protections for participating women, physicians, and facilities. All procedures were compliant with the terms of the Health Insurance Portability and Accountability Act. RESULTS Mean sensitivity was 85.2% (95% confidence interval [CI]: 83.7%, 86.6%) and was significantly lower for radiologists with a greater screening focus (P = .023) but did not significantly differ by total (P = .47), screening (P = .33), or diagnostic (P = .23) volume. The mean false-positive rate was 9.1% (95% CI: 8.1%, 10.1%), with rates significantly higher for radiologists who had the lowest total (P = .008) and screening (P = .015) volumes. Radiologists with low diagnostic volume (P = .004 and P = .008) and a greater screening focus (P = .003 and P = .002) had significantly lower false-positive and cancer detection rates, respectively. Median invasive tumor size and proportion of cancers detected at early stages did not vary by volume. CONCLUSION Increasing minimum interpretive volume requirements in the United States while adding a minimal requirement for diagnostic interpretation could reduce the number of false-positive work-ups without hindering cancer detection. These results provide detailed associations between mammography volumes and performance for policymakers to consider along with workforce, practice organization, and access issues and radiologist experience when reevaluating requirements.
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Affiliation(s)
- Diana S M Buist
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
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Abstract
Women with ductal carcinoma in situ (DCIS) need to comprehend the meaning of the diagnosis and the potential benefits and harms of treatment options. Full and understandable information is a requirement, not an option. However, with DCIS, as with many areas of medicine, a high level of uncertainty about the disease remains. In this article, we define informed medical decision making, review challenges to its implementation, and provide suggestions on how to improve communication with women about the diagnosis and treatment of DCIS.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98104-2499, USA.
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