Purpose

To test the hypothesis that American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) categories for breast density reported by radiologists are lower when digital mammography is used than those reported when film-screen (FS) mammography is used.

Materials and methods

This study was institutional review board approved and HIPAA compliant. Demographic data, risk factors, and BI-RADS breast density categories were collected from five mammography registries that were part of the Breast Cancer Surveillance Consortium. Active, passive, or waiver of consent was obtained for all participants. Women aged 40 years and older who underwent at least two screening mammographic examinations less than 36 months apart between January 1, 2000, and December 31, 2009, were included. Women with prior breast cancer, augmentation, or use of agents known to affect density were excluded. The main sample included 89 639 women with both FS and digital mammograms. The comparison group included 259 046 women with two FS mammograms and 87 066 women with two digital mammograms. BI-RADS density was cross-tabulated according to the order in which the two types of mammogram were acquired and by the first versus second interpretation.

Results

Regardless of acquisition method, the percentage of women with a change in density from one reading to the next was similar. Breast density was lower in 19.8% of the women who underwent FS before digital mammography and 17.1% of those who underwent digital before FS mammography. Similarly, lower density classifications were reported on the basis of the second mammographic examination regardless of acquisition method (15.8%-19.8%). The percentage of agreement between density readings was similar regardless of mammographic types paired (67.3%-71.0%).

Conclusion

The study results showed no difference in reported BI-RADS breast density categories according to acquisition method. Reported BI-RADS density categories may be useful in the development of breast cancer risk models in which FS, digital, or both acquisition methods are used.

Importance

Controversy exists about the frequency women should undergo screening mammography and whether screening interval should vary according to risk factors beyond age.

Objective

To compare the benefits and harms of screening mammography frequencies according to age, breast density, and postmenopausal hormone therapy (HT) use.

Design

Prospective cohort.

Setting

Data collected January 1994 to December 2008 from mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries.

Participants

Data were collected prospectively on 11,474 women with breast cancer and 922,624 without breast cancer who underwent mammography at facilities that participate in the BCSC.

Main outcomes and measures

We used logistic regression to calculate the odds of advanced stage (IIb, III, or IV) and large tumors (>20 mm in diameter) and 10-year cumulative probability of a false-positive mammography result by screening frequency, age, breast density, and HT use. The main predictor was screening mammography interval.

Results

Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively).

Conclusions and relevance

Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

Physician attributes, job satisfaction and confidence in clinical skills are associated with enhanced performance and better patient outcomes. We surveyed 252 pathologists to evaluate associations between enjoyment of breast pathology, demographic/clinical characteristics and diagnostic performance. Diagnostic performance was determined by comparing pathologist assessments of a set of 60 cases with consensus assessments of the same cases made by a panel of experienced pathologists. Eighty-three percent of study participants reported enjoying breast pathology. Pathologists who enjoy breast interpretation were more likely to review ≥10 cases/week (p = 0.003), report breast interpretation expertise (p = 0.013) and have high levels of confidence interpreting breast pathology (p < 0.001). These pathologists were less likely to report that the field was challenging (p < 0.001) and that breast cases make them more nervous than other types of pathology (p < 0.001). Enjoyment was not associated with diagnostic performance. Millions of women undergo breast biopsy annually, thus it is reassuring that although nearly a fifth of practicing pathologists who interpret breast tissue report not enjoying the field, precision is not impacted.

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 (r_spearman=0.51, 95% CI: 0.22, 0.80; P=.0006) and specificity (r_spearman=0.40, 95% CI: 0.30, 0.49; P<.0001).

Conclusion

Different educational approaches to screening and diagnostic imaging should be considered.

Background

Biennial screening mammography retains most of the benefits of annual breast cancer screening with reduced harms. Whether screening guidelines based on race/ethnicity and age would be more effective than age-based guidelines is unknown.

Methods

Mammography data from the Breast Cancer Surveillance Consortium were linked to pathology and tumor databases. The authors identified women aged 40 to 74 years who underwent annual, biennial, or triennial screening mammography between 1994 and 2008. Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (95% CI) of adverse tumor characteristics among 14,396 incident breast cancer cases and 10-year cumulative risks of false-positive recall and biopsy recommendation among 1,276,312 noncases.

Results

No increased risk of adverse tumor characteristics associated with biennial versus annual screening were noted in white women, black women, Hispanic women aged 40 to 49 years, or Asian women aged 50 to 74 years. Hispanic women aged 50 to 74 years who screened biennially versus annually were found to have an increased risk of late-stage disease (OR, 1.6; 95% CI, 1.0-2.5) and large tumors (OR, 1.6; 95% CI, 1.1-2.4). Asian women aged 40 to 49 years who underwent biennial screening had an elevated risk of positive lymph nodes (OR, 3.1; 95% CI, 1.3-7.1). No elevated risks were associated with triennial versus biennial screening. Cumulative false-positive risks decreased markedly with a longer screening interval.

Conclusions

The authors found limited evidence of elevated risks of adverse tumor characteristics with biennial versus annual screening, whereas cumulative false-positive risks were lower. However, elevated risks of late-stage disease in Hispanic women and lymph node-positive disease in younger Asian women who screened less often than annually warrant consideration and replication.

Background

The news media facilitated the rapid dissemination of the findings from the estrogen plus progestin therapy arm of the Women's Health Initiative (EPT-WHI).

Objective

To examine the relationship between the potential exposure to newspaper coverage and subsequent hormone therapy (HT) use. DESIGN/POPULATION: Population-based cohort of women receiving mammography at 7 sites (327,144 postmenopausal women).

Measurements

The outcome was the monthly prevalence of self-reported HT use. Circulation data for local, regional, and national newspapers was used to create zip-code level measures of the estimated average household exposure to newspaper coverage that reported the harmful effects of HT in July 2002.

Results

Women had an average potential household exposure of 1.4 articles. There was substantial variation in the level of average household exposure to newspaper coverage; women from rural sites received less than women from urban sites. Use of HT declined for all average potential exposure groups after the publication of the EPT-WHI. HT prevalence among women who lived in areas where there was an average household exposure of at least 3 articles declined significantly more (45 to 27%) compared to women who lived in areas with <1 article (43 to 31%) during each of the subsequent 5 months (relative risks 0.86-0.92; p < .006 for all).

Conclusions

Greater average household exposure to newspaper coverage about the harms associated with HT was associated with a large population-based decline in HT use. Further studies should examine whether media coverage directly influences the health behavior of individual women.

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.

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.

Rationale and objectives

Evidence is inconsistent about whether radiologists' interpretive performance on a screening mammography test set reflects their performance in clinical practice. This study aimed to estimate the correlation between test set and clinical performance and determine if the correlation is influenced by cancer prevalence or lesion difficulty in the test set.

Materials and methods

This institutional review board-approved study randomized 83 radiologists from six Breast Cancer Surveillance Consortium registries to assess one of four test sets of 109 screening mammograms each; 48 radiologists completed a fifth test set of 110 mammograms 2 years later. Test sets differed in number of cancer cases and difficulty of lesion detection. Test set sensitivity and specificity were estimated using woman-level and breast-level recall with cancer status and expert opinion as gold standards. Clinical performance was estimated using women-level recall with cancer status as the gold standard. Spearman rank correlations between test set and clinical performance with 95% confidence intervals (CI) were estimated.

Results

For test sets with fewer cancers (N = 15) that were more difficult to detect, correlations were weak to moderate for sensitivity (woman level = 0.46, 95% CI = 0.16, 0.69; breast level = 0.35, 95% CI = 0.03, 0.61) and weak for specificity (0.24, 95% CI = 0.01, 0.45) relative to expert recall. Correlations for test sets with more cancers (N = 30) were close to 0 and not statistically significant.

Conclusions

Correlations between screening performance on a test set and performance in clinical practice are not strong. Test set performance more accurately reflects performance in clinical practice if cancer prevalence is low and lesions are challenging to detect.

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.