Detection Of DCIS Research Articles

Evaluation of an AI Model to Assess Future Breast Cancer Risk.

Background Accurate breast cancer risk assessment after a negative screening result could enable better strategies for early detection. Purpose To evaluate a deep learning algorithm for risk assessment based on digital mammograms. Materials and Methods A retrospective observational matched case-control study was designed using the OPTIMAM Mammography Image Database from the National Health Service Breast Screening Programme in the United Kingdom from February 2010 to September 2019. Patients with breast cancer (cases) were diagnosed following a mammographic screening or between two triannual screening rounds. Controls were matched based on mammography device, screening site, and age. The artificial intelligence (AI) model only used mammograms at screening before diagnosis. The primary objective was to assess model performance, with a secondary objective to assess heterogeneity and calibration slope. The area under the receiver operating characteristic curve (AUC) was estimated for 3-year risk. Heterogeneity according to cancer subtype was assessed using a likelihood ratio interaction test. Statistical significance was set at P < .05. Results Analysis included patients with screen-detected (median age, 60 years [IQR, 55-65 years]; 2044 female, including 1528 with invasive cancer and 503 with ductal carcinoma in situ [DCIS]) or interval (median age, 59 years [IQR, 53-65 years]; 696 female, including 636 with invasive cancer and 54 with DCIS) breast cancer and 1:1 matched controls, each with a complete set of mammograms at the screening preceding diagnosis. The AI model had an overall AUC of 0.68 (95% CI: 0.66, 0.70), with no evidence of a significant difference between interval and screen-detected (AUC, 0.69 vs 0.67; P = .085) cancer. The calibration slope was 1.13 (95% CI: 1.01, 1.26). There was similar performance for the detection of invasive cancer versus DCIS (AUC, 0.68 vs 0.66; P = .057). The model had higher performance for advanced cancer risk (AUC, 0.72 ≥stage II vs 0.66 <stage II; P = .037). The AUC for detecting breast cancer in mammograms at diagnosis was 0.89 (95% CI: 0.88, 0.91). Conclusion The AI model was found to be a strong predictor of breast cancer risk for 3-6 years following a negative mammographic screening. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Mann and Sechopoulos in this issue.

Association between radiologists' and facilities' characteristics and mammography screening detection of ductal carcinoma in situ.

The aim of our study was, first, to measure association between radiologists and facilities characteristics and DCIS detection. Second, to assess whether those characteristics affect differently the likelihood of detection of DCIS versus invasive breast cancer. When applicable, we examined whether the identified characteristics were similarly associated with low-grade and high-grade DCIS detection. This retrospective cohort study included 1,750,002 digital screening mammograms (2145 screen-detected DCIS) performed in the Quebec breast cancer screening program between 2007 and 2015 inclusively. The associations between radiologists' and facilities' characteristics and (1) the DCIS detection rate, (2) the invasive detection rate, and (3) the odds of DCIS on invasive detection were assess. For statistically significant associations in the latter analysis, analyses stratified by DCIS grade were performed. Multivariable logistic regression with generalized estimating equations estimates to account for correlation among mammograms was used. Compared to radiologists with recall rate between 5.0 and 9.9%, radiologists with recall rate between 15.0-19.9% and ≥ 20% reached a higher DCIS detection rate, with adjusted detection ratios of, respectively, 1.33 (95% confidence interval = 1.15-1.53) and 1.43 (95% confidence interval = 1.13-1.81). Increase in radiologist' recall rate was statistically significantly associated with an increase in detection of low/intermediate-grade DCIS (P < 0.001), while not in high-grade DCIS (P = 0.15). A major determinant of DCIS detection is the radiologists' recall rate. Abnormalities referred by radiologists with higher recall rates should be identified in order to understand how to decrease recall rate while keeping an optimal DCIS and invasive detection rate.

Identification of Early Molecular Markers for Breast Cancer

Background: Early detection of DCIS is very important because it is a highly curable disease, with a 10-year cancer-specific survival rate of over 97%. The biomarkers and immunehistochemical markers (Osteopontin OPN) SPP1, MUC1 (Epithelial Mucin 1), RRM2 (Ribonucleotidereductase), FOXM1 (Forkhead box M1) DEPDC1 (DEP (Disheveled, EGL-10, and Pleckstrin) domain-containing protein), Nucleolar spindle-associated protein (NUSAP1), EXO1 (Exonuclease 1), are expressed strongly right from DCIS and thereby with early diagnosis of this preinvasive condition with progression to invasive carcinoma, improves the prognosis of breast cancer. Aim: To study the markers (Osteopontin OPN) SPP1, MUC1 (Epithelial Mucin 1), RRM2 (Ribonucleotidereductase), FOXM1 (Forkhead box M1) DEPDC1 (DEP (Disheveled, EGL-10, and Pleckstrin) domain-containing protein), Nucleolar spindle-associated protein (NUSAP1), EXO1 (Exonuclease 1 by immunohistochemistry for early detection and prognostication of breast Cancers. Methods: This is a prospective case control study in 50 females with mammographically suspected and FNAC and biopsy proven Ductal Carcinoma in situ (25 cases) and infiltrating ductal carcinoma (25 cases) with 50 healthy control samples. The paraffin blocks of the tissue sections were stained with hematoxylin and eosin evaluated by light microscopy and immunohistochemistry performed with DEPDC1, NUSAP1, EXO1, RRM2, FOXM1, MUC1, SPP1 (Osteopontin). Observations: In DCIS and invasive ductal carcinoma the immunohistochemical marker expression of DEPDC1, NUSAP1, EXO1, RRM2, FOXM1, MUC1 and SPP1are increased as compared to healthy controls where there is absence of any kind of staining for these IHC markers except for some exceptional case where there is weak positive staining. Conclusions: These IHC markers aid in early detection of DCIS and invasive carcinomas as these markers are not expressed in healthy control tissue. The similarities between antigen expression as evidenced by immunohistochemistry in DCIS and invasive carcinomas in our data suggest that the early detection and treatment of DCIS progressing to invasive carcinoma by detection of biomarkers by immunohistochemistry is of utmost relevance for the survival of patients who are at high risk of developing breast carcinoma.

Nipple-Sparing Mastectomy: Reliability of sub-areolar sampling and frozen section in predicting occult nipple involvement in breast cancer patients

IntroductionThe oncological safety of nipple-areolar complex (NAC) preservation is a concern in the mastectomies performed for cancer indication. The detection of tumor cells during the intraoperative frozen section examination (IE) of sub-areolar/nipple tissue (SAT) leads to the removal of NAC, but frequently the final histology of the nipple is negative for malignancy. This study aims to evaluate the accuracy of SAT examination in predicting occult NAC involvement in case of Nipple-Sparing Mastectomy (NSM). MethodsThe study includes 76 NSM. We evaluated the concordance between histopathologic features of frozen and paraffin-embedded SAT sections. Moreover, we examined the "true margin" (TM), defined as the measurement of the distance between the tumor margin and the edge of the SAT. A margin >1 mm was considered negative. ResultsIn 26/76 cases the IE of the SAT was positive. At the final histology, the NAC was negative in 57.7% of cases. The concordance between frozen and paraffin section examination of the SAT was 92.1%. The three false-positives were low-grade DCIS at the IE, and negative or DIN1a on permanent section. A negative TM seems to predict for a negative NAC (6/6). ConclusionsThe detection of a low-grade DCIS at the IE of the SAT may not be confirmed at the permanent section examination; we recommend caution in removing the NAC in these cases. The evaluation of the TM may improve the accuracy of SAT analysis in predicting occult NAC involvement; in our series, a TM wider than 1 mm correlates with a negative NAC.

Abstract P2-05-31: High-risk breast cancer is less likely to occur in the ductal hyperplasia lesions or low-grade DCIS ∼ Consideration of long-term follow-up observation after surgical biopsy

Abstract &amp;lt;Introduction&amp;gt; Even if many ductal hyperplasia lesions and low grade DCIS are detected by breast cancer screening using high-resolution imaging modalities, we have often experienced high-grade breast cancer as an interval cancer. We might consider whether the detection of ductal hyperplasia lesions and low grade DCIS in breast cancer screening really leads to a decrease in breast cancer death. Therefore, we examined the follow-up periods after the removal of lesions. And we would like to refer to the problem of over-diagnosis and over-treatment of LGDCIS. &amp;lt;Subjects and Methods&amp;gt; At our facility from 1997 to 2012, we examined 354 cases of ductal hyperplasia lesions which were treated with surgical biopsy and followed up with observations spanning at least three years. The ductal hyperplasia lesions shown here are the usual ductal hyperplasia, flat epithelial atypia, atypical ductal hyperplasia, and intraductal papilloma. The median of the follow-up observation period was 73 months. In addition, we had 153 cases of low-grade DCIS patients who underwent follow-up of more than three years without postoperative irradiation. The median of the follow-up period was 63 months. &amp;lt;Result&amp;gt; (1) In ductal hyperplasia lesions, 25 cancers occurred in both breasts. There were 13 cases of DCIS in the histopathological examination (52%) and 12 cases of invasive cancer (46%). In DCIS, low-grade DCIS of Van Nuys1 accounted for 86%. Luminal A was 75% in invasive cancer. Lymph node metastasis was observed in only two cases, with one case having one metastatic lymph node and the other having two. Her2 type and triple-negative type accounted for one case each. Her2 type was microinvasive carcinoma, and Ki67 was 22% in triple negative type. The potential for malignancy in both was not so high. In low-grade DCIS (non-irradiated), 11 cancers occurred in both breasts. There were 8 cases of DCIS (73%) and three cases of invasive cancer (27%). All of the DCIS cases were VanNuys1. All of the invasive cancer cases were luminal A. (2) We compared the cancer occurrence in benign lesions and low-grade DCIS (surgery side). The occurrence rate was 2.2% for benign lesions and 3.2% for low-grade DCIS over a five-year period. There was no significant difference found between the two groups. &amp;lt;Conclusion&amp;gt; High-risk breast cancer is less likely to occur in ductal hyperplasia lesions or low-grade DCIS. In other words, terminal duct lobular unit (TDLU) in both breast who had been affected with ductal hyperplasia or low grade DCIS lost a risk of the occurrence of high grade malignant cancer. Therefore, women with ductal hyperplasia and LGDCIS should be placed in the low-risk group of future breast cancer deaths. Small low grade DCIS might be regarded to be nearly as innocent as benign hyperplastic lesions. Citation Format: Takebe K, Arai T. High-risk breast cancer is less likely to occur in the ductal hyperplasia lesions or low-grade DCIS ∼ Consideration of long-term follow-up observation after surgical biopsy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-31.

Overdiagnosis in breast imaging

The main harm of overdiagnosis is overtreatment. However a form of overdiagnosis also occurs when foci of cancer are found by imaging in addition to the symptomatic lesion when this leads to additional treatment which does not benefit the patient. Even if overtreatment is avoided, knowledge of the diagnosis can still cause psychological harm.Overdiagnosis is an inevitable effect of mammographic screening as the benefit comes from diagnosing breast cancer prior to clinical detectability. Estimates of the rate of overdiagnosis at screening are around 10%. DCIS represents 20% of cancers detected by screening and is the main focus in the overdiagnosis debate. Detection and treatment of low grade DCIS and invasive tubular cancer would appear to represent overdiagnosis in most cases. Supplementary screening with tomosynthesis or US are both likely to increase overdiagnosis as both modalities detect predominantly low grade invasive cancers. MRI causes overdiagnosis because it is so sensitive that it detects real tumour foci which after radiotherapy and systemic therapy do not, in many cases go on and cause local recurrence if the women had had no MRI and undergone breast conservation and adjuvant therapy with these small foci left in situ.

Detection of DCIS and reduced invasive interval cancers

Detection of DCIS and reduced invasive interval cancers

Current Treatment of DCIS

Ductal carcinoma in-situ DCIS is a heterogeneous entity in breast neoplasm with unpredictable biological behavior. This poses challenge in the management of DCIS. Various trials on DCIS have shown good outcome with integral treatment of adequate surgery, radiotherapy and hormonal therapy. Identification of subgroup of DCIS for radiotherapy and hormonal therapy could improve recurrence rate, contralateral tumours incidence and perhaps overall survival. Various risk score calculations could help to direct radiotherapy and hormonal treatment verses surgery alone and to avoid over treatment. Oncotype DX assay could be a new way of risk calculation to direct types of DCIS treatment. The recent increased use of MRI could increase the detection of DCIS and a more accurate extent of disease estimation. This article is a summary of major literatures and major trials result for DCIS.

JNK1 stress signaling is hyper-activated in high breast density and the tumor stroma: Connecting fibrosis, inflammation, and stemness for cancer prevention

Mammography is an important screening modality for the early detection of DCIS and breast cancer lesions. More specifically, high mammographic density is associated with an increased risk of breast cancer. However, the biological processes underlying this phenomenon remain largely unknown. Here, we re-interrogated genome-wide transcriptional profiling data obtained from low-density (LD) mammary fibroblasts (n = 6 patients) and high-density (HD) mammary fibroblasts (n = 7 patients) derived from a series of 13 female patients. We used these raw data to generate a “breast density” gene signature consisting of >1250 transcripts that were significantly increased in HD fibroblasts, relative to LD fibroblasts. We then focused on the genes that were increased by ≥ 1.5-fold (P < 0.05) and performed gene set enrichment analysis (GSEA), using the molecular signatures database (MSigDB). Our results indicate that HD fibroblasts show the upregulation and/or hyper-activation of several key cellular processes, including the stress response, inflammation, stemness, and signal transduction. The transcriptional profiles of HD fibroblasts also showed striking similarities to human tumors, including head and neck, liver, thyroid, lung, and breast cancers. This may reflect functional similarities between cancer-associated fibroblasts (CAFs) and HD fibroblasts. This is consistent with the idea that the presence of HD fibroblasts may be a hallmark of a pre-cancerous phenotype. In these biological processes, GSEA predicts that several key signaling pathways may be involved, including JNK1, iNOS, Rho GTPase(s), FGF-R, EGF-R, and PDGF-R-mediated signal transduction, thereby creating a pro-inflammatory, pro-proliferative, cytokine, and chemokine-rich microenvironment. HD fibroblasts also showed significant overlap with gene profiles derived from smooth muscle cells under stress (JNK1) and activated/infected macrophages (iNOS). Thus, HD fibroblasts may behave like activated myofibroblasts and macrophages, to create and maintain a fibrotic and inflammatory microenvironment. Finally, comparisons between the HD fibroblast gene signature and breast cancer tumor stroma revealed that JNK1 stress signaling is the single most significant biological process that is shared between these 2 data sets (with P values between 5.40E-09 and 1.02E-14), and is specifically associated with tumor recurrence. These results implicate “stromal JNK1 signaling” in the pathogenesis of human breast cancers and the transition to malignancy. Augmented TGF-β signaling also emerged as a common feature linking high breast density with tumor stroma and breast cancer recurrence (P = 5.23E-05). Similarities between the HD fibroblast gene signature, wound healing, and the cancer-associated fibroblast phenotype were also noted. Thus, this unbiased informatics analysis of high breast density provides a novel framework for additional experimental exploration and new hypothesis-driven breast cancer research, with a focus on cancer prevention and personalized medicine.

Magnetic resonance imaging: The evolution of breast imaging

Introduction and aimsTo provide an overview of the principle of current breast MRI, the available evidence concerning its indications and optimum use and future potentials. Methods and resultsTo date sensitivities of 90–91% have been achieved with a specificity of 72–75%. MRI is the most sensitive method for detecting invasive carcinoma and comparable to mammography concerning detection of DCIS. The achievable specificity, false positive and biopsy rates, however, are much lower than for screening mammography thus do not allow its use for screening of the general population. Indications with proven advantages concern screening of women at high risk and special diagnostic problems that cannot be solved by conventional imaging and percutaneous biopsy: search for primary tumour in CUP syndrome, differentiation of nipple retraction, differentiation of scarring versus recurrence and selected difficult cases. There is no proven benefit for its general use for preoperative staging. One major problem may concern the imperfect interface between imaging and surgery. Further research is also needed for the use of MRI in women at intermediate risk. In women at low risk MRI screening is not recommended. Novel possibilities of MRI concern diffusion weighted imaging as well as MR spectroscopy. Their value for improved lesion differentiation is not yet fully established. Their main potential appears to concern an improved and earlier prediction of response to neoadjuvant therapy. Future developments might address development of more specific contrast agents, replacement of vascular enhancing agents by special MR techniques, testing of sodium MRI or image fusion with other imaging modalities. Discussion/conclusionMRI allows new patho-physiological information and thus can complement the information available by conventional methods. Present research should concentrate on improving specificity, improving the interface of imaging and surgery and has to include outcome analyses. Due to issues of specificity the responsible use of MRI should be limited to appropriate indications.

Breast MRI of pure ductal carcinoma in situ: Sensitivity of diagnosis and influence of lesion characteristics

ObjectivesThe purpose of the study was to evaluate the sensitivity of breast MRI in the detection of pure DCIS and to analyze the influence of lesion type and nuclear grade. Methods58 consecutive patients with pathologically proven pure DCIS and preoperatively performed breast MRI were retrospectively reviewed and analyzed. Sensitivities in the detection of DCIS were calculated for MRI and mammography (Mx). Influence of MRI lesion type and nuclear grading on DCIS diagnosis was evaluated. ResultsMRI detected pure DCIS with a sensitivity of 79.3%. The sensitivity of Mx was lower (69%), but the difference was not statistically significant (p=0.345). 46.2% of the DCIS presented as enhancing mass and 53.8% as non-mass-like enhancement (NMLE). None of the masses but 21.4% (n=6) of the NMLE were underestimated as probably benign (BI-RADS® 3). MRI measured lesion sizes showed a moderate correlation (r=0.74) with histopathologically measured lesion sizes. MRI detection rate of DCIS decreased significantly (p=0.0458) with increasing nuclear grade. Calculated sensitivities were 100% for low-grade DCIS, 84.6% for intermediate-grade DCIS, and 66.7% for high-grade DCIS. ConclusionsIn this study MRI could detect pure DCIS more sensitively than Mx. Despite of missing statistically significance preoperative MRI seems to be helpful in patients with DCIS who are eligible for breast conservation. This applies in particular to patients with non-high-grade DCIS because those were significantly more often positive on MRI and significantly more often negative on Mx. Misinterpretation occurs especially in cases of NMLE and high-grade DCIS and therefore a correlation with Mx is also recommended.

Computer‐aided detection should be used routinely to assist screening mammogram interpretation

Computer‐aided detection should be used routinely to assist screening mammogram interpretation

Method of detection of DCIS to predict HER2 overexpression.

1557 Background: Overdiagnosis of DCIS has become a major concern. Overexpression of the human epidermal growth factor receptor-2 (HER2) has been introduced as a prognostic marker that correlates with a higher biologic aggressiveness of breast cancer. We investigated the rate of HER2 overexpression of DCIS diagnosed by breast MRI compared to the DCIS diagnosed by mammography. Aim was to find out whether the additional DCIS diagnosed by MRI represents prognostically relevant disease or whether it will lead to additional overdiagnosis. Methods: During a 5-year period 7,319 women underwent breast MRI in addition to mammography for screening or for diagnostic assessment. A total of 167 women received the final surgical pathology diagnosis of pure DCIS. HER2 receptor status was established by standardized methods and dichotomized as positive (DAKO score 3+ or c-erbB2-amplifikation at FISH) or negative (DAKO score < 3+ or FISH negative). It was available in 127/137 women. We investigated the detection rate of breast MRI and of mammography for DCIS. We compared the HER2 receptor status of all MRI-detected versus all mammography-detected DCIS. Furthermore we compared the HER2 receptor status off only mammography-detected versus only MRI-detected DCIS. Results: Of the 127 DCIS, 95 (75%) were categorized as HER2 negative, and 32 (25%) as HER2 positive. Of the 32 HER2 positive DCIS, 13 (41%) were diagnosed through mammography, and 31 (97%) through MRI. Of the 10 DCIS which were only mammography-detected, one (10%) was HER2 positive. Of the 52 DCIS which were only MRI detected, 21 (40%) were HER2 positive. In the entire cohort, two-thirds of HER2-positive DCIS (66%, 21/32) were only detected by MRI (p < 0.005). Conclusions: DCIS not visible at MRI is virtually always HER2 negative. Two-thirds of HER2 positive DCIS are not visible on mammography, but only diagnosed by MRI. The method of detection of a DCIS correlates with its biologic aggressiveness: Detectability by mammography is correlated with a lower aggressiveness compared with detectability by MRI. MRI-detected additional DCIS are associated with a higher biologic aggressiveness. We conclude that MRI-detected DCIS do not add to mammography-induced overdiagnosis, but represent prognostically relevant disease. No significant financial relationships to disclose.

Diagnostic Accuracy and Prognostic Value of Core Biopsy in the Management of Breast Cancer: A Series of 542 Patients

Core biopsy is considered to be a highly accurate method for gaining preoperative diagnosis of breast cancer. The purpose of this study is to compare the results of core biopsy with those of the surgical excision specimen. A total of 567 core biopsies with subsequent surgical excision were performed. In 488 patients, invasive breast cancer was diagnosed in the preoperative biopsy and in 486 patients (99.6%) the surgical specimen showed identical results. In 160 of the 502 patients (32%) with invasive breast cancer, DCIS was found in the surgical specimen but was not diagnosed in the biopsy. Estrogen and progesterone receptor demonstrated a high rate of agreement, Her2/neu analysis showed a complete concordance in 54% of patients. Core biopsies allow diagnosis of invasive breast cancer with high accuracy. Levels of agreement have to be improved for the detection of DCIS and Her2/neu status.

Detection of DCIS and invasive ductal carcinoma of the breast in human serum by protein profiling (SELDI)

Introduction: Several methods are suited to classify different cancers by testing RNA or protein expression. No method is available to screen for DCIS. This study is performed to differentiate serum samples of healthy women and patients with benign, premalignant and malignant lesions by protein profiling. Additionally the diagnostic value of SELDI-MS (surface-enhanced laser desorption ionisation- mass spectroscopy) for detection of DCIS and invasive ductal carcinoma is investigated. Methods: SELDI is a protein chip based procedure and is used for quantitative measurement of protein mixtures like serum. Here a weak cationic chip is chosen. Obtained protein profiles are combined in an algorithm to correlate expression patterns and histological diagnosis. Blood samples from 112 women are analysed (28 from healthy controls, 27 with benign breast lesions, 25 with DCIS and 32 with invasive ductal carcinoma). Results: SELDI reveals 27 significantly discriminative protein peaks (3000–15000 Da). In an algorithm various combinations of four significant peaks are used. SELDI analysis and data entry into the algorithm reveal a good differentiation between premalignant and malignant lesions and normal controls. Statistical analysis shows a high sensitivity of 0.89 and 0.88 for detection of DCIS and invasive ductal carcinoma in patient serum. Conclusion: Identification of differentially expressed proteins in serum samples related to women with tumors of different malignant progression, by SELDI technique, turned out to be possible. A high prediction strength of nearly 90% for DCIS underlines the importance of this new method. SELDI may become an important screening tool for detection of DCIS and early invasive ductal carcinoma.

Detection and classification of lobular and DCIS (small cell) microcalcifications in digital mammograms

Microcalcifications are detected by fitting a model to every location in the mammogram. Model parameters yielding the best fit are used as features for detection and classification. The fraction of true positive (tp) detection is 60% with 1.23 false detections per cm 2. The rate of correct classification is 69%.

A way to reduce the number of benign breast biopsies in a screening programme

Analysis of ductal carcinoma in situ detected at screening has shown bias towards high grade disease; the consensus of opinion amongst pathologists is the detection of high grade DCIS is important in preventing the subsequent development of invasive cancer some years later. Similarly our analysis his shown that identification of high grade DCIS as microcalcitications facilitates the detection of small high grade invasive tumours at a stage when treatment is much more likely to be effective. There is increasing interest in the role of screening in the surveillance of patients at increased risk of breast cancer those with a significant family history and those with previous biopsy showing epithelial changes associated with increased risk. As yet there is no consensus on how the two manage these patients. Women shown to be genetically predisposed as carriers of the BRCAl or BRCA2 gene should be counselled for possible bilateral mastectomies while those with lesser risk may benefit from regular mammographic screening. However, the evidence for any mortality benefit from such screening remains sparse. Achieving pre-operative diagnosis is important for patient well being and the reintroduction of core biopsy using rapid fire guns has allowed many centres to improve their pre-operative diagnosis rates to above 95% and at the same time dramatically reduce the number of diagnosis surgical biopsies performed for what proves to be benign disease. More recently in the UK some analysis of overall breast cancer mortality benefit has suggested that breast cancer screening may be showing early signs in effect with mortality rates falling, particularly in women in the 50 to 70 age range. Analysis has shown that this fall in mortality is associated with improvement in breast cancer stage rather than being attributable to improved treatment. Similarly data in Nottingham over a 20 year period has demonstrated a dramatic fall in breast cancer mortality which correlates closely with a significant fall in tumour size at the time of diagnosis. This data is very encouraging for a predicted significant fall in mortality attributable to earlier diagnosis by screening.

Detection and Treatment of Ductal Carcinoma In Situ of the Breast-Reply

In Reply. —We described the recent epidemic of DCIS, a breast lesion for which detection has increased with increased mammography utilization. Most reporters grasped the essential message that the increased detection of DCIS poses a clinical enigma and has probably resulted in considerable overtreatment. (Headlines ranged from Ability to Find a Tiny Tumor Poses a Dilemma in the New York Times to Some Breast Cancer May Be Overtreated in USA Today .) There are no good data on the extent to which DCIS in young women leads to invasive cancer in older women. We did not suggest that these lesions are best left undetected but did say that, a large proportion of cases of DCIS never become clinically apparent or life-threatening, it may be that many if not most women with mammographically detected DCIS will not benefit from treatment. Assuming that some women with DCIS eventually have their tumors progress to invasive

The impact of core-biopsy on pre-operative diagnosis rate of screen detected breast cancers

The UK breast screening Surgical Quality Assurance guidelines suggest a target for pre-operative diagnosis of screen detected cancer of over 70%. Core biopsy was introduced in our breast screening assessment clinics in April 1994 and this study reports the impact of introducing core biopsy on the pre-operative diagnosis rate. Between April 1994 and March 1995, 100 cancers were detected. Results of fine needle aspiration cytology and core biopsies were studied to assess the contribution of each to the pre-operative diagnosis rate of cancer and comparison made with results from the previous 2 years. After introducing core biopsy pre-operative diagnosis rates rose from 72% to 90% (P < 0.0002) leading to a 64% reduction in diagnostic biopsies for screen detected cancer. Malignant results were obtained in 61% of first FNA (similar to previous years) and 74% of first core biopsies (combined 87%). Repeat FNA/core diagnosed three further cancers increasing the final pre-operative diagnosis rate to 90%. Final pathological examination after surgical excision demonstrated an increase in the preoperative detection of DCIS from 39% to 82% (P < 0.01) and invasive disease from 80% to 92% (P < 0.02). The introduction of core biopsy has significantly improved our management of screen detected breast cancer.