Abnormal Screening Mammogram Research Articles

A Comparison of Different Intensities of Patient Navigation After Abnormal Mammography.

Background. Patient navigation is a practice strategy to address barriers to timely diagnosis and treatment of cancer. The aim of this study was to examine the effectiveness of varying intensities of patient navigation and timely diagnostic resolution after abnormal mammography. Method. This is a secondary analysis of a subset of women with an abnormal screening or diagnostic mammogram who participated in the "patient navigation in medically underserved areas" 5-year randomized trial. We compared timely diagnostic resolution in women assigned to different intensities of patient navigation including, full navigation intervention, no contact with navigators, or limited contact with navigators. Results. The sample included 1,725 women with abnormal mammogram results. Women who interacted with patient navigators had significantly fewer days to diagnostic resolution after abnormal mammography compared with women who did not interact with patient navigators. Discussion. Results from our study suggest that even limited contact with navigators encourages women to seek more timely diagnostic resolution after an abnormal mammogram, which may offer a low-cost practice strategy to improve timely diagnosis for disadvantaged and underserved women.

Abstract P6-03-11: Differences in serum miRNA signatures in women with pathology-confirmed breast cancer, benign breast diseases and healthy individuals with no cancer history

Abstract [INTRODUCTION] Mammography is the principal non-invasive imaging method of screening for breast cancer around the world. Mammography has been shown to be effective in reducing breast cancer deaths in randomized studies (Tabar et al., 2011 and Duffy et al., 2002). However, screening mammography can result in false positives that require subsequent interventions such as biopsy or interval repeat mammography. Recently, circulating micro RNAs (miRNAs) have been cited as promising minimally invasive markers for breast cancer as well as for various other types of malignancies (Shimomura et al., 2016; Lawrie et al., 2008; Wang et al., 2009; Zhang et al., 2010; Mitchell et al., 2008). In this study, we have developed a new molecular diagnostic platform for the measurement of circulating (serum) miRNAs to assist with the management of women with abnormal screening mammograms. [METHODS] Peripheral venous blood samples were collected in BD Red/Gray gel barrier tubes from patients with untreated breast cancer, patients with benign breast diseases and healthy individuals with no cancer history. The processing from blood to serum was done within six hours of collection and stored at -80°C. Total RNA was extracted from 300uL of the resulting serum using 3D-Gene®RNA extraction reagent (Toray Industries, Inc). Comprehensive miRNA expression analysis was then performed using 3D-Gene® Human miRNA Oligo Chip (Toray Industries, Inc). The average of three pre-selected internal control miRNA (miR-149-3p, miR-2861 and miR-4463) was used to normalize the signals across the different microarrays tested. [RESULTS] RESULTS] All serum specimens used in this study were from subjects enrolled at US clinical sites (83% Caucasian, 15% African American, 2% Asian and others). One hundred fifteen (115) specimens (breast cancer: 40, healthy: 45, benign breast lesions: 30) were selected as a training cohort and used to develop comprehensive discriminants with 1–5 miRNAs using Fisher's linear discriminant analysis. The analysis identified a combination of five miRNAs that could detect breast cancer, and the resulting discriminant equation showed a sensitivity of 90.5%, specificity of 89.5% and accuracy of 89.8%. As test cohorts, (A) 381 subjects (breast cancer: 63, healthy: 160, benign breast lesions: 152), independent from subjects in the training cohort, and (B) 35 subjects who had been referred for breast biopsy were tested. The discrimination performance of the equation for each breast cancer stage (Stage 0: 1, Stage 1: 20, Stage 2: 17, Stage 3: 14, Stage 4: 11) was examined in the test cohorts. Also, information from breast cancer types as well as from benign breast lesions have been used to assess the performance of the discriminant score. The results of these analyses along with a discussion of the potential significance and plans for expanded clinical trials will be presented. Citation Format: Akiyama H, Manlapaz V, Wong C, Yamazaki Y, Knapp M, Ohara S. Differences in serum miRNA signatures in women with pathology-confirmed breast cancer, benign breast diseases and healthy individuals with no cancer history [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-03-11.

Discussion of “Patient navigation reduces time to care for patients with breast symptoms and abnormal screening mammograms”

Dr. McKevitt has given an excellent presentation and together with her colleagues provided a very polished manuscript. Also, Dr. McKevitt and colleagues are to be congratulated for establishing the Rapid Access Breast Clinic in 2009 and doing the retrospective analysis of performance. This study was based on a 2-month snapshot undertaken 5 years ago. As a result, numbers are small with lots of trends and occasional statistically significant observations. The basic message is that creation of a breast dedicated facility with navigation and coordination for patients, providers and both radiology and surgery care teams resulted in greater efficiency of abnormality identification, diagnosis and surgical care. These gains were primarily within the imaging facility and may also relate to expediting practitioner handoffs. We know from the work of the National Quality Forum and the Commission on Cancer, handoffs between practitioners are a weak link in multidisciplinary cancer care. Once the patient was seen by the surgeon in either the Rapid Access Breast Clinic or the traditional system the time to surgery was similar (20–40 days) which is reasonable.

Patient navigation reduces time to care for patients with breast symptoms and abnormal screening mammograms

IntroductionConcern has been raised about delays for patients presenting with breast symptoms in Canada. Our objective was to determine if our Rapid Access Breast Clinic (RABC) improved care for patients presenting with breast symptoms compared to the traditional system (TS). MethodsA retrospective chart review tabulated demographic, surgical, pathology and radiologic information. Wait times to care were determined for patients presenting with symptomatic and screen detected breast problems. ResultsTime from presentation to surgeon evaluation was shorter in the RABC group for patients with breast symptoms (81 vs 35 days, p < .0001) and abnormal screens (72 vs 40 days, p = .092). Cancer patients with abnormal screens had shorter wait times than patients with breast symptoms in the TS (47 vs 70 days, p = .036). ConclusionCoordination of imaging and clinical care reduces wait times in patients with both abnormal screening mammograms and symptomatic breast presentations and should be expanded in our province.

Synchronous Uterine Metastases from Breast Cancer: Case Study and Literature Review.

Breast cancer rarely metastasizes to the uterus. Here, we report two breast cancer patients with synchronous metastases to the uterus. Case 1 highlights a 46-year-old female with invasive ductal carcinoma who presented with a breast mass and was found to have uterine enlargement on positron emission tomography (PET) scan. Biopsy revealed a metastatic 4 mm focus of breast cancer in the background of endometrial hyperplasia. Case 2 reports a 62-year-old postmenopausal female diagnosed with lobular carcinoma of the breast following an abnormal screening mammogram. A routine pap smear necessitated further workup, revealing simultaneous endometrial and cervical metastasis. Both patients did not have any gynecologic symptoms and presented a diagnostic challenge.

Disparities in abnormal mammogram follow‐up time for Asian women compared with non‐Hispanic white women and between Asian ethnic groups

Delays in abnormal mammogram follow-up contribute to poor outcomes. In the current study, the authors examined differences in abnormal screening mammogram follow-up between non-Hispanic white (NHW) and Asian women. The authors used a prospective cohort of NHW and Asian women with a Breast Imaging, Reporting and Data System (BI-RADS) abnormal result of category 0 or 3-plus in the San Francisco Mammography Registry between 2000 and 2010. Kaplan-Meier estimation for the median number of days to follow-up with a diagnostic radiologic test was performed, and the authors compared the percentage of women with follow-up at 30 days, 60 days, and 90 days and no follow-up at 1 year for Asian women overall (and Asian ethnic groups) and NHW women. In addition, the authors assessed the relationship between race/ethnicity and time to follow-up with adjusted Cox proportional hazards models. Among Asian women, Vietnamese and Filipina women had the longest, and Japanese women the shortest, median follow-up (32 days, 28 days, and 19 days, respectively) compared with NHW women (15 days). The percentage of women receiving follow-up at 30 days was lower for Asians versus NHWs (57% vs 77%; P<.0001), and these disparities persisted at 60 days and 90 days for all Asian ethnic groups except Japanese. Asian women had a reduced hazard of follow-up compared with NHW women (adjusted hazard ratio, 0.70; 95% confidence interval, 0.69-0.72). Asian women also had a higher rate of receiving no follow-up compared with NHW women (15% vs 10%; P<.001); among Asian ethnic groups, Filipinas were found to have the highest percentage of women with no follow-up (18.1%). Asian women, particularly Filipina and Vietnamese women, were less likely than NHW women to receive timely follow-up after an abnormal screening mammogram. Research should disaggregate Asian ethnicity to better understand and address barriers to effective cancer prevention. Cancer 2017;123:3468-75. © 2017 American Cancer Society.

Evaluating wait times from screening to breast cancer diagnosis among women undergoing organised assessment vs usual care

Background:Timely coordinated diagnostic assessment following an abnormal screening mammogram reduces patient anxiety and may optimise breast cancer prognosis. Since 1998, the Ontario Breast Screening Program (OBSP) has offered organised assessment through Breast Assessment Centres (BACs). For OBSP women seen at a BAC, an abnormal mammogram is followed by coordinated referrals through the use of navigators for further imaging, biopsy, and surgical consultation as indicated. For OBSP women seen through usual care (UC), further diagnostic imaging is arranged directly from the screening centre and/or through their physician; results must be communicated to the physician who is then responsible for arranging any necessary biopsy and/or surgical consultation. This study aims to evaluate factors associated with diagnostic wait times for women undergoing assessment through BAC and UC.Methods:Of the 2 147 257 women aged 50–69 years screened in the OBSP between 1 January 2002 and 31 December 2009, 155 866 (7.3%) had an abnormal mammogram. A retrospective design identified two concurrent cohorts of women diagnosed with screen-detected breast cancer at a BAC (n=4217; 47%) and UC (n=4827; 53%). Multivariable logistic regression analyses examined associations between wait times and assessment and prognostic characteristics by pathway. A two-sided 5% significance level was used.Results:Screened women with breast cancer were two times more likely to be diagnosed within 7 weeks when assessed through a BAC vs UC (OR=1.91, 95% CI=1.73–2.10). In addition, compared with UC, women assessed through a BAC were significantly more likely to have their first assessment procedure within 3 weeks of their abnormal mammogram (OR=1.25, 95% CI=1.12–1.39), ⩽3 assessment procedures (OR=1.54, 95% CI=1.41–1.69), ⩽2 assessment visits (OR=1.86, 95% CI=1.70–2.05), and ⩾2 procedures per visit (OR=1.41, 95% CI=1.28–1.55). Women diagnosed through a BAC were also more likely than those in UC to have imaging (OR=1.99, 95% CI=1.44–2.75) or a biopsy (OR=3.69, 95% CI=2.64–5.15) vs consultation only at their first assessment visit, and two times more likely to have a core or FNA biopsy than a surgical biopsy (OR=2.08, 95% CI=1.81–2.40). Having ⩽2 assessment visits was more likely to reduce time to diagnosis for women assessed through a BAC compared with UC (BAC OR=10.58, 95% CI=8.96–12.50; UC OR=4.47, 95% CI=3.94–5.07), as was having ⩽3 assessment procedures (BAC OR=4.97, 95% CI=4.26–5.79; UC OR=2.95, 95% CI=2.61–3.33). Income quintile affected wait times only in women diagnosed in UC, with those in the two highest quintiles more likely to receive a diagnosis in 7 weeks.Conclusions:Women with screen-detected breast cancer in OBSP were more likely to have shorter wait times if they were diagnosed through organised assessment. This might be as a result of women diagnosed through a BAC having more procedures per visit, procedures scheduled in shorter intervals, and imaging or biopsy on their first visit. Given the significant improvement in timeliness to diagnosis, women with abnormal mammograms should be managed through organised assessment.

Time to follow-up of an abnormal mammogram in women with diabetes: a population-based study.

Women with diabetes have a higher breast cancer incidence and mortality. They are also significantly less likely to undergo screening mammography and present with more advanced stage than women without diabetes. The purpose of this study was to examine if women with diabetes are more likely to have delays in follow‐up of abnormal mammograms, compared to women without diabetes. Using population‐based health databases, this retrospective cohort study examined women between the ages of 50 and 74, with and without diabetes, living in the province of Ontario, Canada, who underwent screening through a centralized program and who had an abnormal mammogram between 2003 and 2012. We compared rates of follow‐up of a diagnostic test within 180 days, as well as likelihood of mastectomy or excision procedure and a diagnosis of breast cancer. Following an abnormal screening mammogram, 97.5% of women with diabetes had a diagnostic procedure within 180 days compared to 97.9% of women without diabetes. After adjustment for other factors, women with diabetes were only 3% less likely to have follow‐up testing after an abnormal mammogram than women without diabetes (hazard ratio [HR] 0.97, 95% CI: 0.96–0.99, P < 0.001). The majority of Ontario women who underwent screening mammography through a centralized screening program had timely follow‐up of an abnormal mammogram, with no meaningful delays in those who had diabetes. The results of this study suggest that diagnostic delays after screening do not significantly contribute to higher breast cancer mortality in women with diabetes.

Using semi-Markov processes to study timeliness and tests used in the diagnostic evaluation of suspected breast cancer.

Diagnostic evaluation of suspected breast cancer due to abnormal screening mammography results is common, creates anxiety for women and is costly for the healthcare system. Timely evaluation with minimal use of additional diagnostic testing is key to minimizing anxiety and cost. In this paper, we propose a Bayesian semi-Markov model that allows for flexible, semi-parametric specification of the sojourn time distributions and apply our model to an investigation of the process of diagnostic evaluation with mammography, ultrasound and biopsy following an abnormal screening mammogram. We also investigate risk factors associated with the sojourn time between diagnostic tests. By utilizing semi-Markov processes, we expand on prior work that described the timing of the first test received by providing additional information such as the mean time to resolution and proportion of women with unresolved mammograms after 90days for women requiring different sequences of tests in order to reach a definitive diagnosis. Overall, we found that older women were more likely to have unresolved positive mammograms after 90days. Differences in the timing of imaging evaluation and biopsy were generally on the order of days and thus did not represent clinically important differences in diagnostic delay. Copyright © 2016 John Wiley & Sons, Ltd.

Women with abnormal screening mammography lost to follow-up: An experience from Taiwan.

Breast cancer has the highest incidence among all cancers for women in Taiwan. The current screening policy in Taiwan suggested a biennial mammography for all women 40 to 69 years of age. A recommendation for additional testing is recommended for women with a BI-RADS result of 0 or 4; a request made via postal mail. Approximately 20% of high-risk patients do not receive additional follow-up. Therefore, we aimed to explore the causes of these patients being lost to follow-up, despite an abnormal mammogram. Two questionnaires were designed separately according to the conceptual framework of the Health Belief Model. Study participants, women who received a screening mammography at the National Taiwan University Hospital in 2011 with a BI-RAD of 0 or 4, were interviewed via telephone. The dependent variable was receipt of follow-up or not. The analyses were performed by using χ2 tests and logistic regression models. In total, 528 women were enrolled in the study: 51.2% in BI-RADS 0 group and 56.6% in BI-RADS 4, respectively. In the BI-RADS 0 group, those patients who received a follow-up examination cited the most likely causes to be physician suggestion, health implications, and concerns regarding breast cancer. Patients who did not receive a follow-up examination cited a lack of time and a perception of good personal health as primary reasons. In the BI-RADS 4 group, those patients who received a follow-up examination cited the physician's recommendation and a recognition of the importance of follow-up examinations. Patients who did not receive a follow-up examination cited having received follow-up at another hospital and a desire for a second opinion. In the BI-RADS 0 group, multivariate analysis showed that patients with higher scores in the “perceived benefits” domain were statistically more likely to receive a follow-up examination. There was no significant difference in perceived threats, perceived barriers, action cues, or self-efficacy between groups. We conclude that additional education to raise breast cancer awareness in the general public and healthcare providers will be needed to improve the rate of follow-up examinations after an abnormal screening mammogram.

Idiopathic granulomatous mastitis: imaging update and review

ObjectivesThe purpose of this study was to review the imaging features of idiopathic granulomatous mastitis (IGM) with clinical and pathology correlation.MethodsWith institutional review board (IRB) approval, a retrospective search of the surgical pathology database from January 2000 to July 2015 was performed. Clinical, imaging and histology findings were reviewed. Cases of granulomatous mastitis without a known source, diagnosed with percutaneous or surgical biopsy, were included in our analysis.ResultsSeventeen cases of IGM were identified with imaging available for review. The majority of patients presented with a palpable abnormality, whereas a minority were asymptomatic with an abnormal screening mammogram. At imaging, IGM most often demonstrated a focal asymmetry at mammography, a hypoechoic mass with irregular or angular margins at ultrasound, and robust enhancement with mixed progressive and plateau kinetics at magnetic resonance imaging (MRI). Axillary lymph nodes were reactive in appearance at ultrasound. Molecular breast imaging performed in one case showed mild focal asymmetric radiotracer uptake.ConclusionIGM is a rapidly progressive rare inflammatory condition of the breast resulting in non-necrotizing granuloma formation. Imaging features mimic breast carcinoma and diagnosis can be difficult. Radiologists’ awareness of this condition is essential to prevent delayed or unnecessary treatment.Teaching points• Idiopathic granulomatous mastitis is rapidly progressive inflammatory condition.• Imaging features may mimic breast carcinoma or infection.• Ultrasound shows irregular hypoechoic masses with increased vascularity and sinus tracts.• MRI shows irregular, enhancing masses or non-mass enhancement with microabscesses.• MRI is useful for assessment of breast involvement and response to treatment.

Frequency and Determinants of a Short-Interval Follow-up Recommendation After an Abnormal Screening Mammogram

PurposeAfter imaging assessment of an abnormal screening mammogram, a follow-up examination 6 months later is recommended to some women. Our aim was to identify which characteristics of lesions, women, and physicians are associated to such short-interval follow-up recommendation in the Quebec Breast Cancer Screening Program. MethodsBetween 1998 and 2008, 1,839,396 screening mammograms were performed and a total of 114,781 abnormal screens were assessed by imaging only. Multivariate analysis was done with multilevel Poisson regression models with robust variance and generalized linear mixed models. ResultsA short-interval follow-up was recommended in 26.7% of assessments with imaging only, representing 2.3% of all screens. Case-mix adjusted proportion of short-interval follow-up recommendations varied substantially across physicians (range: 4%-64%). Radiologists with high recall rates (≥15%) had a high proportion of short-interval follow-up recommendation (risk ratio: 1.82; 95% confidence interval: 1.35-2.45) compared to radiologists with low recall rates (<5%). The adjusted proportion of short-interval follow-up was high (22.8%) even when a previous mammogram was usually available. ConclusionsShort-interval follow-up recommendation at assessment is frequent in this Canadian screening program, even when a previous mammogram is available. Characteristics related to radiologists appear to be key determinants of short-interval follow-up recommendation, rather than characteristics of lesions or patient mix. Given that it can cause anxiety to women and adds pressure on the health system, it appears important to record and report short-interval follow-up and to identify ways to reduce its frequency. Short-interval follow-up recommendations should be considered when assessing the burden of mammography screening.

Abstract B35: Disparities in follow up after abnormal mammogram for multiple Asian subpopulations

Abstract Introduction: The burden of breast cancer among certain Asian subpopulations is higher than previously estimated, underscoring the need for close scrutiny of Asian disparities across the breast cancer continuum from prevention through survivorship. A critical point in this process, timely and complete follow-up of screening abnormalities, is known to be inadequate among women in minority groups but has not yet been studied among disaggregated Asian populations. The objective of this investigation was to assess and compare the timeliness in follow-up after abnormal mammogram among White and Asian American women in the San Francisco Bay Area. Methods: Using data from the San Francisco Mammography Registry (SFMR), we identified women with an index abnormal screening mammogram result of BIRADS 0/3+ between the years 2000-2010. Our study sample included women who self-report White or Asian race/ ethnicity, ages 30 and older who received screening services at 10 participating SFMR-facilities. We first used chi-square statistics to compare median days to diagnostic follow-up after abnormal mammogram by patient characteristics including race/ethnicity. Cumulative percent plots were constructed to visually display the percentage of racial/ethnic groups with follow-up at multiple time intervals (i.e., 30 days, 60 days). We then conducted hierarchical regression analyses that adjust for the multilevel nature of the data, controlling for within-facility clustering of observations, estimating the associations between follow-up and sociodemographic characteristics including age and education, as well as family history of breast cancer. Subgroup comparisons identified differences in these factors which might explain abnormal mammogram follow-up disparities. Results: The total sample was 54,028 women, 70% White and 30% Asian. Among Asians, 16.2% were Chinese, 6.7% Filipina, 1.8% Japanese, 1.1% Vietnamese, 2.4% Other Asian, and 1.4% Mixed Asian. The mean age of women was 53.4 years, and the majority fell within the range of 40-74 years recommended for screening. The proportion of women who did not receive follow-up within one year after an index abnormal mammogram was 11.1% (n=6023). A higher proportion of Asian women did not receive follow-up compared to Whites (15% vs 10%). Among Asian groups, Filipinas had the highest percentage of women not receiving follow-up (18%) while Japanese women had the lowest (10.4%). In comparing those who received follow-up and those who did not, a higher proportion of women with no follow-up had lower education levels (24% vs 15%). Median time to diagnostic follow-up for White and Asian women combined was 18 days. The median follow-up time was 15 days for Whites and 26 days for Asians. The median follow-up time differed significantly among Asian ethnic groups: Japanese women had the shortest (19 days) followed by Filipinas (28 days). Vietnamese women had the longest (30 days). Hierarchical regression model results with Whites and Asians, accounting for sociodemographic variables and the effect of facility, indicate that women who did not complete high school and Asian women had higher odds of no follow-up after an abnormal mammogram at 30, 60, and 90 days compared to women with a graduate degree and Whites, respectively OR 1.3, CI: 1.16-1.41, and OR 1.2, CI: 1.14-1.27. Race was no longer significant at 60 and 90 days. For regression analyses comparing Whites and Asians by ethnicity, controlling for facility, Chinese, Filipina, Other Asian and Mixed Asian were more likely than White women to not receive follow-up, even after accounting for facilities at 30 days. At 60 days, only Filipinas were significantly more likely to receive no follow-up. At 90 days, Filipina women had slightly higher odds of no follow-up compared to Whites (OR 1.1, CI: 1.02-1.28). Conclusion: We observed disparities in timeliness to follow-up between White and Asian women and among Asian ethnic groups in the first 30-days after an abnormal screening mammogram. Disaggregation of ethnicity can identify subpopulations most in need of breast cancer control, and to provide more specific information on care delivery patterns. Citation Format: Kim Hanh Nguyen, Leah Karliner, Rena Pasick. Disparities in follow up after abnormal mammogram for multiple Asian subpopulations. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B35.

Abstract B82: Performance of digital diagnostic mammography by race

Abstract Background: Diagnostic mammography is used to evaluate women who have signs or symptoms of breast cancer or who have an abnormal screening mammogram. Diagnostic mammography typically involves the acquisition of additional images and is usually done to assess a specific area of concern. The performance of diagnostic mammography (how well this tool detects cancers) is known to vary by the radiologist interpreting the image. However, other factors such as race and type of imaging modality may also impact the performance. A prior study found that diagnostic mammography performance differed by race for film examinations but to our knowledge, no studies have examined if performance differs by race for digital examinations. Hence, we sought to ascertain if the diagnostic mammography performance of digital differed among black and white women in the United States. Methods: Using the Carolina Mammography Registry (CMR) data from 2004-2011 we included all digital diagnostic mammograms performed among black and white women ages 18 and older. The CMR is a prospective population-based breast imaging registry in North Carolina that collects patient demographic, risk factor, and clinical information each time a woman receives mammography. This data is linked to pathology and cancer outcome data. We included diagnostic mammograms, defined as those being performed for symptomatic reasons or for the workup of an abnormal screening examination. To determine the performance of diagnostic mammography, each diagnostic mammogram was categorized as true positive, false negative, true negative, and false positive according to the BI-RADS code assigned by the radiologist and cancer outcomes ascertained in the one-year follow-up period. We computed the diagnostic mammography performance measures of sensitivity, specificity, positive predictive value of the biopsy (PPV2), and the cancer detection rate (CDR) using standard definitions. We compared these performance measures and the CDR among black and white women. We adjusted for age, breast density, history of previous breast procedures, family history of breast cancer, time since last mammogram, and tumor characteristics, including size, grade, stage, type, estrogen receptor, progesterone receptor, and HER2 which could impact the ability to detect cancers. We used a multilevel model to adjust for differences between radiologists interpreting the images and to account for correlated observations within women. Results: We included 42,891 digital mammography examinations of which 22.8% were among black women and 77.3% were among white women. A total of 1,670 breast cancers were detected, with 22.2% among black women and 77.8% among white women. In unadjusted analyses, sensitivity was higher for blacks than whites (84.6% versus 80.9% respectively), specificity was lower for blacks than whites (90.2% versus 92.6%), PPV2 was lower for blacks than whites (27.9% versus 31.6%), and CDR was higher for blacks than whites (36.3/1000 examinations versus 33.0/1000 examinations). After adjusting for the radiologists' effect, as well as patient and tumor characteristics, the models detected significant racial differences for all performance measures. Sensitivity was 5.1% higher for blacks than whites (p-value for difference &amp;lt;0.0001), specificity was 2.2% lower for blacks (p&amp;lt;0.0001), PPV2 was 1.3% lower for blacks (p=0.038), and CDR was 0.17/1000 higher for blacks (p=0.005). Conclusions: Using data from a large population-based mammography registry we found differences in the performance of digital diagnostic mammography for black and white women. Black women have higher sensitivity on digital diagnostic mammography than white women even after controlling for differences in tumor characteristics. In addition, black women have lower specificity compared with white women, resulting in black women undergoing more workups than white women. Citation Format: Louise M. Henderson, Thad Benefield, Mary W. Marsh, Mari Nakayoshi. Performance of digital diagnostic mammography by race. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B82.

Abstract B79: Trends in mammography quality benchmarks met over time: Moving beyond the Mammography Quality Standards Act to address breast cancer disparities

Abstract Backround: In 2007, the Metropolitan Chicago Breast Cancer Taskforce (The Taskforce) was initiated to identify the reasons for an alarming Black/White breast cancer mortality gap in metropolitan Chicago and to propose solutions. One hypothesis raised was that unequal access to high quality breast cancer screening and treatment care may be a significant driver of Chicago's breast cancer disparity. While there is growing interest in the role of breast cancer screening quality in explaining black/white breast cancer mortality gap, there is no research to our knowledge assessing quality measures about the breast cancer screening processes within facilities across the state of Illinois. We summarize data and report trends on 11 breast cancer screening metrics from 3 years of mammography quality data surveillance for facilities in Illinois. Methods: The Taskforce collected aggregate data on 11 breast cancer screening quality metrics for calendar years 2006, 2009, and 2011, including the number of screening mammograms that: received follow-up imaging within 30 days and 12 months; received a biopsy recommendation within 12 months of the screen; resulted in a biopsy recommendation within 12 months; resulted in a biopsy (following recommendation) within 60 days and 12 months of the screen, respectively. Finally, we requested the number of cancers diagnosed within 12 months of an abnormal screening mammogram and the number of these that were minimal and early stage cancers. Data were analyzed for the 32 facilities that submitted metrics across all 3 years. The change in the mean number of benchmarks met was estimated using linear regression using a generalized estimating equations approach with exchangeable correlation matrix and robust standard errors to account for clustering by site. At each time point 95% confidence intervals were estimated. Results: Out of 11 possible metrics, the average number of benchmarks met by each facility for 2006, 2009 and 2011 was 4.88, 7.06 and 8.09, respectively. This represented a 0.65 increase in the overall mean number of benchmarks met by calendar year (95%CI=0.44, 0.75) (or an overall 1.61 increase in the overall mean number of benchmarks met per time point, 95%CI=1.16, 1.97). With respect to individual benchmarks, the proportion of facilities able to show that they met the benchmarks increased substantially between 2006 and 2011 for many benchmarks including cancer detection rate (0.66 to 0.91, p=0.008), proportion of breast cancers diagnosed as minimal (0.28 to 0.88, p=0.0000) and early stage (0.22 to 0.66, p=0.000). Other benchmarks remained unmet by a majority of facilities despite showing substantial improvement over time. These included timely imaging within 30 days of the screen (0.28 to 0.44, p=0.077), and timely biopsy within 60 days of the screen (0.13 to 0.42, p=0.002). Discussion: The American College of Radiology recommends that facilities meet certain additional quality benchmarks above and beyond the audit requirements of the Mammography Quality Standards Act. These include measuring the proportion of abnormal screening mammograms, timeliness of follow-up, extent of screen-detection (i.e., cancer detection rate for screening mammograms), and ability to detect small and early stage tumors. To date, none of these recommendations have been incorporated into MQSA guidelines. The results of this quality improvement project show an overall improvement across time in the average number of quality benchmarks institutions can demonstrate that they meet. Much of this improvement likely stems from an increased ability to collect and report the data needed to construct these measures. Lack of timeliness of diagnostic imaging and biopsy services remain a clear shortcoming for many facilities. Citation Format: Katherine Y. Tossas-Milligan, Bethliz Irizarry, AnneMarie Murphy, Garth H. Rauscher. Trends in mammography quality benchmarks met over time: Moving beyond the Mammography Quality Standards Act to address breast cancer disparities. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B79.

Clinical roles of breast 3T MRI, FDG PET/CT, and breast ultrasound for asymptomatic women with an abnormal screening mammogram

BackgroundMagnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) show promise for molecular cancer imaging. We evaluated 3T MRI, FDG PET/CT, and ultrasound images for asymptomatic women with an abnormal screening mammogram. MethodsThe Institutional Review Board of Kaohsiung Veterans General Hospital (Kaohsiung, Taiwan) approved the study. Patients provided written informed consent. A total of 11,865 screening mammograms of 118,65 women were performed at our facility between January 2011 and December 2012. Fifty-three asymptomatic women (mean age, 53.3 years) whose screening mammograms had a Breast Imaging Reporting and Data System (BI-RADS) category of 4 or 5 were ultimately enrolled in this study. Breast 3T MRI, FDG PET/CT, and breast ultrasound were performed before biopsy. All imaging modalities were compared by lesion-by-lesion analyses. ResultsFifty-nine breast lesions (28 malignant and 31 benign lesions) from 53 women were analyzed. The sensitivity, specificity, and accuracy for 28 breast cancers were 96%, 77%, and 86%, respectively, for breast 3T MRI; 50%, 100%, and 76%, respectively, for FDG PET,CT; and 61%, 87%, and 74%, respectively, for breast ultrasound. One 0.8-cm invasive breast cancer was missed by the screening mammogram, but detected by breast 3T MRI and FDG PET/CT. The sensitivity for detecting breast cancer was significantly higher with MRI than with PET/CT or ultrasound (for all, p < 0.01). The specificity for detecting breast cancer was significantly higher for PET/CT than for breast MRI (p = 0.02). The sensitivity exhibited by 3T breast MRI and FDG PET/CT for 16 noninvasive breast cancers was 94% and 25%, respectively. ConclusionOn screening mammograms, breast 3T MRI showed higher sensitivity but less specificity than FDG PET/CT for detecting asymptomatic breast cancers.

Patient and Radiologist Characteristics Associated With Accuracy of Two Types of Diagnostic Mammograms.

Earlier studies of diagnostic mammography found wide unexplained variability in accuracy among radiologists. We assessed patient and radiologist characteristics associated with the interpretive performance of two types of diagnostic mammography. Radiologists interpreting mammograms in seven regions of the United States were invited to participate in a survey that collected information on their demographics, practice setting, breast imaging experience, and self-reported interpretive volume. Survey data from 244 radiologists were linked to data on 274,401 diagnostic mammograms performed for additional evaluation of a recent abnormal screening mammogram or to evaluate a breast problem, between 1998 and 2008. These data were also linked to patients' risk factors and follow-up data on breast cancer. We measured interpretive performance by false-positive rate, sensitivity, and AUC. Using logistic regression, we evaluated patient and radiologist characteristics associated with false-positive rate and sensitivity for each diagnostic mammogram type. Mammograms performed for additional evaluation of a recent mammogram had an overall false-positive rate of 11.9%, sensitivity of 90.2%, and AUC of 0.894; examinations done to evaluate a breast problem had an overall false-positive rate of 7.6%, sensitivity of 83.9%, and AUC of 0.871. Multiple patient characteristics were associated with measures of interpretive performance, and radiologist academic affiliation was associated with higher sensitivity for both indications for diagnostic mammograms. These results indicate the potential for improved radiologist training, using evaluation of their own performance relative to best practices, and for improved clinical outcomes with health care system changes to maximize access to diagnostic mammography interpretation in academic settings.

Abstract B89: Timeliness in follow-up after abnormal mammography screening among Asian groups

Abstract Background: Treatment of breast cancer at the earliest possible stage results from a combination of screening for non-palpable abnormalities and timely and appropriate follow-up of abnormal test results. Studies have addressed Black-White differences in follow-up of abnormal mammograms but little is known about other groups including Asian Americans, a population composed of distinct ethnic sub-groups with substantial heterogeneity in risk factors that correspond with important to differences in breast cancer rates. In this study we aimed to assess completion and timeliness of diagnostic follow-up after an abnormal mammogram between White and Asian women and among disaggregated Asian ethnic subgroups. Methods: Using data from the San Francisco Mammography Registry, we identified women with an index abnormal screening mammogram result of BIRADS 0/3+ between the years 2000-2010. Our study sample included women who self-report White or Asian race/ ethnicity, ages 40 and older. Our outcomes were: 1) proportion of women without diagnostic follow-up within a year of their index mammogram, and 2) median days to diagnostic follow-up. Results: We identified 54028 White and Asian women between 2000 and 2010 in the SFMR data. Seventy percent of women were White and 30% were Asians. Among Asians, 16.2% were Chinese, 6.7% Filipina, 1.8% Japanese, 1.1% Vietnamese, 2.4% Other Asian, and 1.4% Mixed Asian. The majority of women were between the ages of 40-59 (67%). A total of 6023 (11.1%) of women did not receive follow-up within one year after an index abnormal mammogram. A higher proportion of Asian women did not receive follow-up compared to Whites (15% vs 10%). Among Asian groups, Filipinas had the highest percentage of women not receiving follow-up (18%) while Japanese women had the lowest (10.4%). In comparisons of individuals who received follow-up to those who did not, a higher proportion of women with no follow-up had lower education levels (24% vs 15%). Median time to diagnostic follow-up for White and Asian women combined was 18 days. The median follow-up time was 15 days for Whites, and 26 days for Asians. Among Asians, the median follow-up time differed significantly among ethnic groups: Japanese women had the lowest (19 days) and Vietnamese women the longest (30 days) followed by Filipinas (28 days). Conclusion: We observed disparities in timeliness to follow-up between White and Asian women and among Asian ethnic groups. Disaggregation of ethnicity can identify subpopulations most in need of breast cancer control, and to provide more specific information on breast cancer patterns. Citation Format: Kim H. Nguyen, Leah Karliner, Rena J. Pasick. Timeliness in follow-up after abnormal mammography screening among Asian groups. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B89. doi:10.1158/1538-7755.DISP13-B89

Online support: Impact on anxiety in women who experience an abnormal screening mammogram

ObjectivesTo determine whether an online support tool can impact anxiety in women experiencing an abnormal mammogram. Materials and methodsWe developed an online support system using the Comprehensive Health Enhancement Support System (CHESS) designed for women experiencing an abnormal mammogram as a model. Our trial randomized 130 of these women to online support (the intervention group) or to a list of five commonly used Internet sites (the comparison group). Surveys assessed anxiety and breast cancer worry, and patient satisfaction at three important clinical time points: when women were notified of their abnormal mammogram, at the time of diagnostic imaging, and at the time of biopsy (if biopsy was recommended). ResultsStudy participants in the intervention group showed a significant decrease in anxiety at the time of biopsy compared to the comparison group (p = 0.017). However, there was no significant difference in anxiety between the intervention group and the comparison group at the time of diagnostic work-up. We discontinued assessment of patient satisfaction after finding that many women had substantial difficulty answering the questions that referenced their physician, because they did not understand who their physician was for this process of care. ConclusionThe combination of the inability to identify the physician providing care during the mammography work-up and anxiety effects seen only after an interaction with the breast imaging team may indicate that online support only decreases the anxiety of women in concert with direct interpersonal support from the healthcare team.

Abnormal screening mammogram follow-up: Improving time and timeliness benchmarks.

6631 Background: Abnormal screening mammograms cause significant patient distress. Current benchmarks for timeliness of care for additional imaging after abnormal screening assess the time interval...