Undiagnosed Breast Cancer: Features at Supplemental Screening US

Abstract

To retrospectively investigate the reasons for and features of undiagnosed cancers at previous supplemental screening ultrasonography (US) in women who subsequently received a diagnosis of breast cancer. The institutional review board approved this retrospective study and waived the requirement to obtain informed patient consent. The study consisted of 230 women (median age, 49 years; age range, 29-81 years) with 230 pairs of US examinations (prior and subsequent examinations) performed between December 2003 and August 2013 who were found to have cancer (median interval, 12 months; range, 2-24 months). The authors compared the clinical-pathologic features of patients with negative findings on prior images with those of patients with visible findings on prior images. Findings visible at prior US were classified as actionable or underthreshold by means of a blinded review by five radiologists. Lesions classified as Breast Imaging Reporting and Data System category 4 or 5 by fewer than three readers were determined to be underthreshold. Reasons for undiagnosed cancers and their imaging features were analyzed. Among the 230 prior US examinations, 72 (31.3%) showed visible findings and 158 (68.7%) showed negative findings. High-nuclear-grade cancers and triple-negative cancers were more common in patients with negative findings than in those with visible findings (P = .023 and P = .006, respectively). Blinded review revealed that 57 of the 72 visible findings (79%) were actionable. Misinterpretation (39% [28 of 72 lesions]) and multiple distracting lesions (17% [12 of 72 lesions]) were the two most common reasons for missing these actionable findings, which showed more noncircumscribed margins than did underthreshold findings (P = .028). At supplemental screening breast US, close attention should be paid to the presence of a margin that is not circumscribed, and multiple lesions should be separately assessed to reduce the number of missed breast cancers.