The Benefits of Early Detection: Evidence From Modern International Mammography Service Screening Programs

Research from randomized controlled trials initiated up to 60 years ago consistently confirms that regular screening with mammography significantly reduces breast cancer mortality. Despite this success, there is ongoing debate regarding the efficacy of screening, which is confounded by technologic advances and concerns about cost, overdiagnosis, overtreatment, and equitable care of diverse patient populations. More recent screening research, designed to quell the debates, derives data from variable study designs, each with unique strengths and weaknesses. This article reviews observational population-based screening research that has followed the early initial long-term randomized controlled trials that are no longer practical or ethical to perform. The advantages and disadvantages of observational data and study design are outlined, including the three subtypes of population-based observational studies: cohort/case-control, trend, and incidence-based mortality/staging. The most recent research, typically performed in countries that administer screening mammography to women through centralized health service programs and directly track patient-specific outcomes and detection data, is summarized. These data are essential to understand and inform construction of effective new databases that facilitate continuous assessment of optimal screening techniques in the current era of rapidly developing medical technology, combined with a focus on health care that is both personal and equitable.

A Data Set and Deep Learning Algorithm for the Detection of Masses and Architectural Distortions in Digital Breast Tomosynthesis Images

IMPORTANCE

Breast cancer screening is among the most common radiological tasks, with more than 39 million examinations performed each year. While it has been among the most studied medical imaging applications of artificial intelligence, the development and evaluation of algorithms are hindered by the lack of well-annotated, large-scale publicly available data sets.

OBJECTIVES

To curate, annotate, and make publicly available a large-scale data set of digital breast tomosynthesis (DBT) images to facilitate the development and evaluation of artificial intelligence algorithms for breast cancer screening; to develop a baseline deep learning model for breast cancer detection; and to test this model using the data set to serve as a baseline for future research.

DESIGN, SETTING, AND PARTICIPANTS

In this diagnostic study, 16 802 DBT examinations with at least 1 reconstruction view available, performed between August 26, 2014, and January 29, 2018, were obtained from Duke Health System and analyzed. From the initial cohort, examinations were divided into 4 groups and split into training and test sets for the development and evaluation of a deep learning model. Images with foreign objects or spot compression views were excluded. Data analysis was conducted from January 2018 to October 2020.

EXPOSURES

Screening DBT.

MAIN OUTCOMES AND MEASURES

The detection algorithm was evaluated with breast-based free-response receiver operating characteristic curve and sensitivity at 2 false positives per volume.

RESULTS

The curated data set contained 22 032 reconstructed DBT volumes that belonged to 5610 studies from 5060 patients with a mean (SD) age of 55 (11) years and 5059 (100.0%) women. This included 4 groups of studies: (1) 5129 (91.4%) normal studies; (2) 280 (5.0%) actionable studies, for which where additional imaging was needed but no biopsy was performed; (3) 112 (2.0%) benign biopsied studies; and (4) 89 studies (1.6%) with cancer. Our data set included masses and architectural distortions that were annotated by 2 experienced radiologists. Our deep learning model reached breast-based sensitivity of 65% (39 of 60; 95% CI, 56%-74%) at 2 false positives per DBT volume on a test set of 460 examinations from 418 patients.

CONCLUSIONS AND RELEVANCE

The large, diverse, and curated data set presented in this study could facilitate the development and evaluation of artificial intelligence algorithms for breast cancer screening by providing data for training as well as a common set of cases for model validation. The performance of the model developed in this study showed that the task remains challenging; its performance could serve as a baseline for future model development.

Establishing the efficacy and safety of the novel use of common salt for the treatment of pyogenic granuloma

BACKGROUND

Recurrent bleeding episodes are often a cause of significant anxiety in patients with pyogenic granuloma (PG). The idea of using common salt for the treatment of PG arose from the need for a relatively safe and effective treatment because of the recurrent nature of the lesion.

METHODS

A prospective open-label uncontrolled study of 50 patients was conducted. All cases were treated with ordinary table salt from a commercially available package. White soft paraffin was first applied over the perilesional skin, then sufficient salt to cover the entire lesion was applied and the area was occluded with surgical adhesive tape. All patients were followed up for any complications or recurrence.

RESULTS

Complete resolution of the lesion without any residual scar was seen in 100% of the cases, and 94% reported a decrease in the bleeding tendency of the lesion as an immediate response. The mean time to complete resolution was 14.77 days. Recurrence was noted in one patient after 11 months of resolution.

CONCLUSION

Owing to the relative ease in application, lack of scarring and excellent response, we consider salt application to be an ideal treatment for PG lesions, especially in children and anxious patients reluctant to undergo any procedure.

Mapping the Ultrasound Landscape to Define Point-of-Care Ultrasound and Diagnostic Ultrasound: A Proposal From the Society of Radiologists in Ultrasound and ACR Commission on Ultrasound

Current descriptions of ultrasound evaluations, including use of the term "point-of-care ultrasound" (POCUS), are imprecise because they are predicated on distinctions based on the device used to obtain images, the location where the images were obtained, the provider who obtained the images, or the focus of the examination. This is confusing because it does not account for more meaningful distinctions based on the setting, comprehensiveness, and completeness of the evaluation. In this article, the Society of Radiologists in Ultrasound and the members of the American College of Radiology Ultrasound Commission articulate a map of the ultrasound landscape that divides sonographic evaluations into four distinct categories on the basis of setting, comprehensiveness, and completeness. Details of this classification scheme are elaborated, including important clarifications regarding what ensures comprehensiveness and completeness. Practical implications of this framework for future research and reimbursement paradigms are highlighted.

Benefits and Harms of Breast Cancer Screening: A Systematic Review

IMPORTANCE

Patients need to consider both benefits and harms of breast cancer screening.

OBJECTIVE

To systematically synthesize available evidence on the association of mammographic screening and clinical breast examination (CBE) at different ages and intervals with breast cancer mortality, overdiagnosis, false-positive biopsy findings, life expectancy, and quality-adjusted life expectancy.

EVIDENCE REVIEW

We searched PubMed (to March 6, 2014), CINAHL (to September 10, 2013), and PsycINFO (to September 10, 2013) for systematic reviews, randomized clinical trials (RCTs) (with no limit to publication date), and observational and modeling studies published after January 1, 2000, as well as systematic reviews of all study designs. Included studies (7 reviews, 10 RCTs, 72 observational, 1 modeling) provided evidence on the association between screening with mammography, CBE, or both and prespecified critical outcomes among women at average risk of breast cancer (no known genetic susceptibility, family history, previous breast neoplasia, or chest irradiation). We used summary estimates from existing reviews, supplemented by qualitative synthesis of studies not included in those reviews.

FINDINGS

Across all ages of women at average risk, pooled estimates of association between mammography screening and mortality reduction after 13 years of follow-up were similar for 3 meta-analyses of clinical trials (UK Independent Panel: relative risk [RR], 0.80 [95% CI, 0.73-0.89]; Canadian Task Force: RR, 0.82 [95% CI, 0.74-0.94]; Cochrane: RR, 0.81 [95% CI, 0.74-0.87]); were greater in a meta-analysis of cohort studies (RR, 0.75 [95% CI, 0.69 to 0.81]); and were comparable in a modeling study (CISNET; median RR equivalent among 7 models, 0.85 [range, 0.77-0.93]). Uncertainty remains about the magnitude of associated mortality reduction in the entire US population, among women 40 to 49 years, and with annual screening compared with biennial screening. There is uncertainty about the magnitude of overdiagnosis associated with different screening strategies, attributable in part to lack of consensus on methods of estimation and the importance of ductal carcinoma in situ in overdiagnosis. For women with a first mammography screening at age 40 years, estimated 10-year cumulative risk of a false-positive biopsy result was higher (7.0% [95% CI, 6.1%-7.8%]) for annual compared with biennial (4.8% [95% CI, 4.4%-5.2%]) screening. Although 10-year probabilities of false-positive biopsy results were similar for women beginning screening at age 50 years, indirect estimates of lifetime probability of false-positive results were lower. Evidence for the relationship between screening and life expectancy and quality-adjusted life expectancy was low in quality. There was no direct evidence for any additional mortality benefit associated with the addition of CBE to mammography, but observational evidence from the United States and Canada suggested an increase in false-positive findings compared with mammography alone, with both studies finding an estimated 55 additional false-positive findings per extra breast cancer detected with the addition of CBE.

CONCLUSIONS AND RELEVANCE

For women of all ages at average risk, screening was associated with a reduction in breast cancer mortality of approximately 20%, although there was uncertainty about quantitative estimates of outcomes for different breast cancer screening strategies in the United States. These findings and the related uncertainty should be considered when making recommendations based on judgments about the balance of benefits and harms of breast cancer screening.

Efficacy and tolerability of cefditoren pivoxil in uncomplicated skin and skin structure infections in Indian patients

Background:

Uncomplicated skin and skin structure infections (uSSSI) are commonly encountered community-acquired infections and are typically confined to the superficial layers of the skin. Hence, they seldom lead to the destruction of skin structures.

Aims:

To evaluate the efficacy and tolerability of cefditoren pivoxil in uSSSI in Indian patients.

Methods:

One hundred and seventy-eight patients diagnosed with uncomplicated SSSI were enrolled in this randomized, comparative, multicentric study. Patients received either cefditoren pivoxil or cefdinir for ten days. Efficacy was assessed both clinically and microbiologically. Safety evaluation consisted of reporting of type, frequency, severity, and causal relationship of adverse events.

Results:

One hundred and fifty-one patients completed the study. Clinical and bacteriological efficacy of cefditoren pivoxil was comparable to that of cefdinir in the treatment of uSSSI. One hundred and five patients were eligible for per protocol (PP) analysis of bacteriological outcome and clinical efficacy. Clinical cure or improvement was achieved in 98.00% patients treated with cefditoren pivoxil and 98.18% patients treated with cefdinir. In the modified Intent to Treat (mITT) patient population, clinical cure or improvement was recorded in 97.33% patients treated with cefditoren pivoxil and 96.20% patients treated with cefdinir. Microbiological eradication (or presumed eradication) was recorded in 88.00% patients treated with cefditoren pivoxil and 94.55% patients treated with cefdinir. The above differences in the outcome rates between the two drugs were not statistically significant. Six adverse events (AEs) (two in cefditoren group and four in cefdinir group) were reported in this study.

Conclusion:

Cefditoren pivoxil 200 mg b.i.d. was effective and well tolerated in the treatment of uSSSI.

Breast self-examination: defining a cohort still in need

BACKGROUND

The value of breast self-examination (BSE) to detect early breast cancer is controversial.

METHODS

Within an institutional review board-approved prospective study, 147 high-risk women were enrolled from 2004 to 2007. Yearly clinical examination, BSE teaching, and mammography were performed simultaneously followed by interval breast magnetic resonance imaging (MRI). Women underwent additional BSE teaching at 6 months. Women reporting a mass on BSE underwent clinical evaluation.

RESULTS

Fourteen breast cancers were detected in 12 women. BSE detected 6/14 breast cancers versus 6/14 detected by MRI and 2/14 by mammography. Of 24 masses detected by BSE, 6/24 were malignant. The sensitivity, specificity, and predictive value of BSE to detect breast cancer were 58.3%, 87.4%, and 29.2%, respectively. The sensitivity, specificity, and predictive value of a Breast Image Reporting and Data System (BI-RADS) score of >or=4 on MRI were 66.7%, 88.9%, and 34.8%, respectively.

CONCLUSIONS

BSE detects new breast cancers in high-risk women undergoing screening mammogram, CBE, and yearly breast MRI.

The influence of increased ambient lighting on mass detection in mammograms

RATIONALE AND OBJECTIVES

Recent research has provided evidence that in reading rooms equipped with liquid crystal displays (LCDs), a measured increase of ambient lighting may improve clinicians' detection performance. In agreement with this research, the American College of Radiology (ACR) has recommended a moderate increase of ambient lighting in mammography reading rooms. This study was designed to examine the effect of a controlled increase of ambient lighting in mammography reading rooms on the diagnostic performance of breast imaging radiologists.

MATERIALS AND METHODS

Four breast imaging radiologists read 86 mammograms (43 containing subtle cancerous masses and 43 normal) under low (E = 1 lux) and elevated (E = 50 lux) ambient lighting levels on a Digital Imaging and Communications in Medicine-calibrated, medical-grade LCD. Radiologists were asked to identify cancerous masses and to rate their detection confidence. Observer areas under the curve (AUCs) were calculated using a receiver-operating characteristic analysis of fully paired results. Additionally, average observer selection times under both ambient lighting levels were determined.

RESULTS

Average radiologist AUCs decreased with elevated ambient lighting (0.78 +/- 0.03 to 0.72 +/- 0.04). Observer performance differences, however, were of the same order of magnitude as interobserver variability and were not statistically significant. Average selection times under increased ambient lighting remained constant or decreased, with the greatest decrease occurring for false-positive (20.4 +/- 18.9 to 14.4 +/- 9.6 seconds) and true-positive (18.0 +/- 13.8 to 12.9 +/- 9.4 seconds) selections.

CONCLUSION

The results agree with those of previous studies in that observer performance differences under a controlled increase of ambient lighting are not statistically significant. On the basis of these findings and ACR guidelines, a moderate increase of ambient lighting in mammography reading rooms is still suggested, but further research with additional cases and observers should be considered.

Family information service (FIS) in a BRCA1 extended family

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Background: Considering that 10% of breast cancer is hereditary, it is essential to effectively educate hereditary cancer family members regarding the syndrome, cancer risk, genetic testing and cancer control options. Researchers at Creighton University (CU) have for many years provided family (group-oriented) information services (FISs) for hereditary cancer families. Methods: Such a session was held in collaboration with a genetic counselor in a community where many members of an extended hereditary breast-ovarian cancer family with a known BRCA1 mutation reside. Family members helped contact relatives and invited them to attend the full-day FIS at a local hospital. Informal presentations were provided by a CU geneticist/oncologist, a CU nurse counselor, and a local genetic counselor. Questions and comments were encouraged. An opportunity to provide a blood sample for genetic testing was offered. Results: Contacting relatives for the FIS identified more than 400 family members from previously unknown branches. Many attendees indicated this was their first opportunity to learn about this hereditary cancer syndrome, their risk, and recommended cancer control options. Patient-stated benefits of the FIS included increased communication of cancer risk among family members as well as with their physicians, motivation to become more vigilant with screening and health management and receipt of initial cancer risk education in a non-threatening venue. Conclusions: The FIS is a relatively simple, cost-effective educational cancer control program that increases communication among family members and their physicians, educates high-risk individuals and provides an opportunity for genetic testing which will ultimately provide an accurate cancer risk status and thereby alter health management and cancer control strategies.

No significant financial relationships to disclose.

Stereotactic breast biopsy of noncalcified lesions: a cost-minimization analysis comparing 14-gauge multipass automated core biopsy to 14- and 11-gauge vacuum-assisted biopsy

A decision model was used to compare the relative costs of the 14-gauge automated gun technique to the 14-gauge and 11-gauge vacuum-assisted techniques for stereotactic biopsy of noncalcified breast lesions. Probability and cost variables were estimated from clinical experience with 76 automated gun biopsies, seventy-eight 14-gauge vacuum-assisted biopsies and thirty-nine 11-gauge vacuum-assisted biopsies. The 14-gauge automated gun was the preferred strategy from a cost standpoint: the 14-gauge vacuum technique was 1.19 times more expensive, and the 11-gauge was 1.22 times more expensive.

Computer-Aided Detection of Amorphous Calcifications

OBJECTIVE

Computer-aided detection (CAD) systems have been used successfully to detect malignant calcifications on mammography, with sensitivities ranging from 86% to 99%. Amorphous calcifications are a subset of small indistinct calcifications of intermediate concern that have a 20% likelihood of being malignant and that are frequently overlooked on mammography. The purpose of our study was to determine the sensitivity of one commercially available CAD system for detecting amorphous calcifications.

MATERIALS AND METHODS

A commercially available CAD system evaluated mammograms of 82 patients with 85 mammographically detected and histologically sampled groups of amorphous calcifications (21 malignant, 14 high risk, and 50 benign). The sensitivity of the system for detecting the calcifications on at least one image of the two-view mammographic examination (case sensitivity) and on each individual mammographic image (image sensitivity) was determined. Findings were correlated with results from large core needle biopsy or surgical excision in each case.

RESULTS

The CAD system detected amorphous calcifications in 43 of 85 cases (case sensitivity, 51%) and in 59 of 146 mammographic images (image sensitivity, 40%). The case sensitivities by histologic outcome were 57% for malignant calcifications, 29% for high-risk calcifications, and 54% for benign calcifications. An average of 2.0 false-positive marks were displayed per case.

CONCLUSION

The CAD sensitivity for malignant amorphous calcifications is markedly lower than previously reported for all malignant calcifications. Breast imaging radiologists who use CAD systems should continue to search diligently for these difficult-to-detect lesions.

Viability and drug susceptibility testing of M. leprae using mouse footpad in 37 relapse cases of leprosy

Mycobacteria leprae isolates obtained from 37 referral relapse cases of leprosy (37 skin and 10 nerve biopsy samples) received during the years 1994-2001, were tested for viability and drug sensitivity in the mouse footpad. A significant M. leprae yield in the footpads of control mice was obtained, with 32/47 (68%) isolates (from 26 cases) thus confirming viability. Of the 28 isolates successfully drug tested, 6 (21%) were resistant to one or more drugs. All except one, were multidrug treated cases (5/24 = 21%). One of the isolates was resistant to all three drugs, i.e., dapsone (di-aminodiphenyl sulphone, DDS), rifampin (RFP), and clofazimine (CLF). Two were resistant to two drugs, i.e., DDS and RFP, and each of the others were mono resistant to DDS, RFP, or CLF. Notably, one of the isolates that showed combined resistance to DDS and RFP was derived from a borderline tuberculoid case. Also, in one case skin and nerve showed that discordance viz: M. leprae derived from skin were resistant to RFP, while those derived from nerve tested sensitive to all three drugs, indicating tissue related difference.

Plagiochasma appendiculatum as a biotest for water quality assessment

A thalloid pathogen-free liverwort, Plagiochasma appendiculatum, was exposed to different pollution stresses, especially heavy metals, synthesized in the laboratory, to simulate pollutants reported to occur in industrial areas. The plant was found to be sensitive to mercury and copper. Thallus injury and chlorophyll content showed effects with increasing exposure to metals. In contrast, the plant was found to be resistant to lead, zinc and chromium. The plant showed growth in some concentrations of these metals, hence suggesting their accumulation. In this paper, the possible use of Plagiochasma in the assessment of water quality, especially for heavy metals, is discussed, with special reference to thallus deterioration as a simple biomonitoring parameter.

Stereotactic biopsy of noncalcified breast lesions: utility of vacuum-assisted technique compared to multipass automated gun technique

The purpose of this study was to evaluate the stereotactic 14-gauge, vacuum-assisted biopsy technique in diagnosing noncalcified breast lesions. Stereotactic biopsy of 116 noncalcified breast lesions was performed with either 14-gauge, vacuum-assisted technique or multipass, automated large-core technique. The number of core samples and time required for each biopsy were compared. Outcome for each technique was compared based on recommendations after the mammographic-histologic review process. Results from surgical excision and mammographic follow-up were reviewed. The vacuum-assisted technique obtained more tissue cores per lesion than the automated gun technique, showed marginal decrease in number of repeat biopsies for discordant results, and required fewer short-term follow-up mammograms, although the difference did not achieve statistical significance. The vacuum-assisted technique can be used successfully to sample noncalcified breast masses, with marginal improvement over the automated gun technique.

Inhibition of DNA helicase II unwinding and ATPase activities by DNA-interacting ligands. Kinetics and specificity

Although DNA helicases play important roles in the processing of DNA, little is known about the effects of DNA-interacting ligands on these helicases. Therefore, the effects of a wide variety of DNA-binding ligands on the unwinding and ATPase reactions catalyzed by Escherichia coli DNA helicase II were examined. DNA minor groove binders and simple DNA intercalators did not inhibit helicase II. However, DNA intercalators, such as mitoxantrone and nogalamycin, which position functionalities in the major groove upon binding duplex DNA, were potent inhibitors of helicase II. To determine the mechanism by which mitoxantrone inhibited helicase II, the unwinding and DNA-dependent ATPase activities of helicase II were measured using a spectrum of double- and single-stranded DNA substrates. Using either a 71-base pair (bp) M13mp7 partially duplexed DNA substrate or a 245-bp bluntended, fully duplexed DNA substrate, the apparent Ki value for inhibition by mitoxantrone of both the unwinding and ATPase reactions was approximately 1 microM for both substrates, suggesting that the mechanism of inhibition of helicase II by mitoxantrone is the same for both substrates and requires the presence of double-stranded structure. To strengthen this conclusion, the ability of mitoxantrone to inhibit the DNA-dependent ATPase activity of helicase II was determined using two single-stranded substrates, poly(dT) and the 245-bp substrate after heat denaturation. Using either substrate, mitoxantrone inhibited the ATPase activity of helicase II far less effectively. Thus, these results indicate that the intercalation of mitoxantrone into double-stranded DNA, with accompanying placement of functionalities in the major groove, generates a complex that impedes helicase II, resulting in both inhibition of ATP hydrolysis and unwinding activity. Furthermore, we report here that DNA-binding ligands inhibit the unwinding activity of helicases I and IV and Rep protein from E. coli, demonstrating that the inhibition observed for helicase II is not unique to this enzyme.