False-positive Examinations Research Articles

The American Cancer Society National Lung Cancer Roundtable strategic plan: Provider engagement and outreach.

The American Cancer Society National Lung Cancer Roundtable strategic plan for provider engagement and outreach addresses barriers to the uptake of lung cancer screening, including lack of provider awareness and guideline knowledge about screening, concerns about potential harms from false-positive examinations, lack of time to implement workflows within busy primary care practices, insufficient infrastructure and administrative support to manage a screening program and patient follow-up, and implicit bias based on sex, race/ethnicity, social class, and smoking status. Strategies to facilitate screening include educational programming, clinical reminder systems within the electronic medical record, decision support aids, and tools to track nodules that can be implemented across a diversity of practices and health care organizational structures. PLAIN LANGUAGE SUMMARY: The American Cancer Society National Lung Cancer Roundtable strategic plan to reduce deaths from lung cancer includes strategies designed to support health care professionals, to better understand lung cancer screening, and to support adults who are eligible for lung cancer screening by providing counseling, referral, and follow-up.

A Semiautonomous Deep Learning System to Reduce False Positives in Screening Mammography.

Purpose To evaluate the ability of a semiautonomous artificial intelligence (AI) model to identify screening mammograms not suspicious for breast cancer and reduce the number of false-positive examinations. Materials and Methods The deep learning algorithm was trained using 123 248 two-dimensional digital mammograms (6161 cancers) and a retrospective study was performed on three nonoverlapping datasets of 14 831 screening mammography examinations (1026 cancers) from two U.S. institutions and one U.K. institution (2008-2017). The stand-alone performance of humans and AI was compared. Human plus AI performance was simulated to examine reductions in the cancer detection rate, number of examinations, false-positive callbacks, and benign biopsies. Metrics were adjusted to mimic the natural distribution of a screening population, and bootstrapped CIs and P values were calculated. Results Retrospective evaluation on all datasets showed minimal changes to the cancer detection rate with use of the AI device (noninferiority margin of 0.25 cancers per 1000 examinations: U.S. dataset 1, P = .02; U.S. dataset 2, P < .001; U.K. dataset, P < .001). On U.S. dataset 1 (11 592 mammograms; 101 cancers; 3810 female patients; mean age, 57.3 years ± 10.0 [SD]), the device reduced screening examinations requiring radiologist interpretation by 41.6% (95% CI: 40.6%, 42.4%; P < .001), diagnostic examinations callbacks by 31.1% (95% CI: 28.7%, 33.4%; P < .001), and benign needle biopsies by 7.4% (95% CI: 4.1%, 12.4%; P < .001). U.S. dataset 2 (1362 mammograms; 330 cancers; 1293 female patients; mean age, 55.4 years ± 10.5) was reduced by 19.5% (95% CI: 16.9%, 22.1%; P < .001), 11.9% (95% CI: 8.6%, 15.7%; P < .001), and 6.5% (95% CI: 0.0%, 19.0%; P = .08), respectively. The U.K. dataset (1877 mammograms; 595 cancers; 1491 female patients; mean age, 63.5 years ± 7.1) was reduced by 36.8% (95% CI: 34.4%, 39.7%; P < .001), 17.1% (95% CI: 5.9%, 30.1%: P < .001), and 5.9% (95% CI: 2.9%, 11.5%; P < .001), respectively. Conclusion This work demonstrates the potential of a semiautonomous breast cancer screening system to reduce false positives, unnecessary procedures, patient anxiety, and medical expenses. Keywords: Artificial Intelligence, Semiautonomous Deep Learning, Breast Cancer, Screening Mammography Supplemental material is available for this article. Published under a CC BY 4.0 license.

Клінічний випадок захворювання, підозрілого на хворобу Лайма, з незвичайними результатами серологічного обстеження

The article p examination: positive results of IgM and IgG antibodies to B. burgdorferi, obtained by the method of blot analysis (WB), and negative results of examination by the method of enzyme immunoassay (ELISA), which resents a case of a disease suspected of Lyme disease with unusual results of serological were made later in two other laboratories. The advantages of the two-stage diagnosis of Lyme disease with the sequential use of ELISA and WB and the possible consequences of the diagnosis of the disease using only one laboratory technique are considered. Attention is drawn to differences in the interpretation of WB results according to the criteria of the Center for Disease Control (CDC, USA) and manufacturers of alternative test systems. Factors that can contribute to false-positive examination results are considered: depending on the patient (the presence of concomitant rheumatic, infectious diseases) and on the erroneous interpretation of the results of laboratory tests (considering weakly positive bands as a positive result, the presence of several bands within one, neglecting a slight shift of the band in relation to its location in control, etc.). Attention is also drawn to the impacton the results of the study of the presence of «anamnestic» antibodies in a certain percentage of people living inareas endemic for Lyme disease. Based on the above theoretical propositions, a thorough analysis was carried out regarding the compliance of the clinical manifestations of the case of the disease considered in the article with the criteria of the early localized form of Lyme disease. On the basis of the criteria found in scientific publications, a clinical and epidemiological comparison of the patient’s data with the results of laboratory examination was carried out regarding their reliability. A conclusion is made regarding the need to rely on clinical data when diagnosing Lyme disease, and to consider laboratory examination results as additional confirmation of the diagnosis. It is emphasized that the high specificity (98%) of the laboratory examination is ensured only due to the two-stage research method with the sequential use of ELISA and WB. In case of questionable WB results, clinical and epidemiological data should be compared with the results of laboratory examination for their reliability. Keywords: Borrelia burgdorferi, diagnosis, IgM IgG immunoblot, Lyme disease, serology

A Prospective Comparative Evaluation of Handheld Ultrasound Examination (HHUS) or Automated Ultrasound Examination (ABVS) in Women with Dense Breast.

Mammography is the gold standard examination for breast cancer screening. In women with high breast density, mammography has reduced sensitivity. In these women, an additional screening option is often recommended. This study prospectively compared ABVS and HHUS in women with mammography-negative examinations and dense breasts. Materials and methods: N = 222 women were evaluated prospectively and consecutively between January 2019 and June 2019 (average age 53 years; range 39–89). McNemar’s test and ROC analysis were used with standard statistical software. We included in the study both symptomatic and asymptomatic women with dense breasts. Women included underwent both HHUS and ABVS after mammography with independent reading. Results: N = 33/222 (15%) women resulted in having breast cancer. Both ABVS and HHUS identified more cancers than standard mammography, and both HHUS and ABVS had false-positive examinations: n = 13 for HHUS and n = 12 for ABVS. We found that HHUS had better accuracy than ABVS. The AUC of the ROC was 0.788 (95% CI 0.687–0.890) for ABVS and 0.930 (95% CI 0.868–0.993) for HHUS. This difference was statistically significant (p < 0.05). Conclusions: HHUS was more accurate in breast cancer detection than ABVS. Multicentric studies must confirm these data for supplemental imaging in women with dense breasts.

Impact of digital breast tomosynthesis (DBT) on finding types leading to true-positive and false-positive examinations

PurposeTo investigate the frequencies of finding types with combined digital breast tomosynthesis (DBT) and digital mammography (DM) leading to true-positive (TP) and false-positive (FP) examinations. Materials and methodsConsecutive screening mammograms at an academic medical center from March 2008 to February 2011 (DM group) and from January 2013 to December 2017 (DBT/DM group) were retrospectively reviewed. Multivariable logistic regression models were used to compare the proportions of mammographic finding types leading to TP and FP examinations between the two groups. ResultsThe DM group had 554 TP and 7278 FP examinations, and the DBT/DM group had 1271 TP and 14,544 FP examinations. The finding type of calcifications led to a lower proportion of TP examinations in the DBT/DM than DM group (34.3% versus 47.7%, p < 0.001) but also a lower proportion of FP examinations (18.7% versus 21.7%, p < 0.001). Mass led to a higher proportion of TP examinations in the DBT/DM than DM group (5.7% versus 1.3%, p < 0.001) but also a higher proportion of FP examinations (4.6% versus 0.3%, p < 0.001). Asymmetry led to a higher proportion of TP examinations in the DBT/DM than DM group (58.3% versus 50.4%, p = 0.03) and a lower proportion of FP examinations (75.9% versus 77.6%, p < 0.001). Architectural distortion led a similar proportion of TP examinations in the DBT/DM and DM groups (1.7% versus 0.7%, p = 0.12) but a higher proportion of FP examinations (0.8% versus 0.4%, p = 0.007). ConclusionsMammographic findings leading to TP and FP examinations have shifted with the addition of DBT to DM.

Pulmonary COVID-19: Multimodality Imaging Examples.

The full digital presentation is available online.

On-Call Examinations for Acute Onset of Flashes, Floaters, or Curtain by Junior Ophthalmology Residents: Outcomes, Safety, and Resource Use

To determine whether an on-call system serviced by junior residents can safely triage patients with symptoms concerning for posterior vitreous detachment, retinal tear, and retinal detachment. Quality improvement study structured as a prospective cohort study. All symptomatic patients seen in 2017 by an on-call junior resident were followed up (257 patients). Those with follow-up within 6 months of initial presentation (228 patients, 246 unique encounters) were included. We prospectively tracked all symptomatic patients seen on-call by a junior resident in 2017 at a major academic medical center. Incidence and predictors of true retinal tears or detachments, false-positive tears or detachments, false-negative tears or detachments, and resource use. Of 246 symptomatic encounters, 83 (33.7%) had a perceived retinal tear or detachment. Residents used B-scan ultrasonography in a high number of encounters (41.0%). Ten (4.1%) false-positive tears or detachments were identified, with the presence of intraretinal hemmorhage predicting a false-positive examination (adjusted odds ratio, 3.86; 95% confidence interval, 1.1-13.5). Thirteen (5.3%) false-negative tears and no false-negative detachments were identified. Eleven (84.6%) false-negative tears underwent follow-up within days based on high-risk characteristics, and no false-negative tears progressed to detachment at follow-up. Measures of resource use included an in-person confirmation of examination findings by the senior resident or fellow in 59 encounters (24.0%) and shorter follow-up times to a retina rather than a nonretina clinic for 52 of 151 patients who showed no pathologic features on initial examination. Junior residents can safely provide on-call triage of patients with symptoms concerning for a posterior vitreous detachment, retinal tear, or retinal detachment. The system requires moderate resource use, including occasional confirmatory examinations by a second physician and shorter follow-up times to retina clinic for high-risk patients.

The Adoption and Impact on Performance of an Automated OutcomesFeedback Application for Tomosynthesis Screening Mammography.

To evaluate a tomosynthesis screening mammography automated outcomes feedback application's adoption and impact on performance. This prospective intervention study evaluated a feedback application that provided mammographers subsequent imaging and pathology results for patients that radiologists had personally recalled from screening. Deployed to 13 academic and 5 private practice attending radiologists, adoption was studied from March 29, 2018, to March 20, 2019. Radiologists indicated if reviewed feedback would influence future clinical decisions. For a subset of eight academic radiologists consistently interpreting screening mammograms during the study, performance metrics were compared pre-intervention (January 1, 2016, to September 30, 2017) and post-intervention (October 1, 2017 to June 30, 2018). Abnormal interpretation rate, positive predictive value of biopsies performed, sensitivity, specificity, and cancer detection rate were compared using Pearson's χ2 test. Logistic regression models were fit, adjusting for age, race, breast density, prior comparison, breast cancer history, and radiologist. The 18 radiologists reviewed 68.5% (1,398 of 2,042) of available feedback cases and indicated that 17.4% of cases (243 of 1,398) could influence future decisions. For the eight academic radiologist subset, after multivariable adjustment with comparison to pre-intervention, average abnormal interpretation rate decreased (from 7.5% to 6.7%, adjusted odds ratio [aOR] 0.86, P < .01), positive predictive value of biopsies performed increased (from 40.6% to 51.3%, aOR 1.48, P= .011), and specificity increased (from 93.0% to 93.9%, aOR 1.17, P < .01) post-intervention. There was no difference in cancer detection rate per 1,000 examinations (from 5.8 to 6.1, aOR 1.01, P= .91) or sensitivity (from 81.2% to 78.7%, aOR 0.84, P= .47). Radiologists used a screening mammography automated outcomes feedback application. Its use decreased false-positive examinations, without evidence of reduced cancer detection.

The Value of Patient and Tumor Factors in Predicting Preoperative Breast MRI Outcomes.

To identify patient and tumor features that predict true-positive, false-positive, and negative breast preoperative MRI outcomes. Using a breast MRI database from a large regional cancer center, the authors retrospectively identified all women with unilateral breast cancer who underwent preoperative MRI from January 2005 to February 2015. A total of 1396 women with complete data were included. Patient features (ie, age, breast density) and index tumor features (ie, type, grade, hormone receptor, human epidermal growth factor receptor type 2/neu, Ki-67) were extracted and compared with preoperative MRI outcomes (ie, true positive, false positive, negative) using univariate (ie, Fisher exact) and multivariate machine learning approaches (ie, least absolute shrinkage and selection operator, AutoPrognosis). Overall prediction performance was summarized using the area under the receiver operating characteristic curve (AUC), calculated using internal validation techniques (bootstrap and cross-validation) to account for model training. At the examination level, 181 additional cancers were identified among 1396 total preoperative MRI examinations (median patient age, 56 years; range, 25-94 years), resulting in a positive predictive value for biopsy of 43% (181 true-positive findings of 419 core-needle biopsies). In univariate analysis, no patient or tumor feature was associated with a true-positive outcome (P > .05), although greater mammographic density (P = .022) and younger age (< 50 years, P = .025) were associated with false-positive examinations. Machine learning approaches provided weak performance for predicting true-positive, false-positive, and negative examinations (AUC range, 0.50-0.57). Commonly used patient and tumor factors driving expert opinion for the use of preoperative MRI provide limited predictive value for determining preoperative MRI outcomes in women. Supplemental material is available for this article. © RSNA, 2020See also the commentary by Grimm in this issue.

Breast Cancer Screening with Digital Breast Tomosynthesis: Are Initial Benefits Sustained?

Background Performance metrics with digital breast tomosynthesis (DBT) are based on early experiences. There is limited research on whether the benefits of DBT are sustained. Purpose To determine whether improved screening performance metrics with DBT are sustained over time at the population level and after the first screening round at the individual level. Materials and Methods A retrospective review was conducted of screening mammograms that had been obtained before DBT implementation (March 2008 to February 2011, two-dimensional digital mammography [DM] group) and for 5 years after implementation (January 2013 to December 2017, DBT1-DBT5 groups, respectively). Patients who underwent DBT were also categorized according to the number of previous DBT examinations they had undergone. Performance metrics were compared between DM and DBT groups and between patients with no previous DBT examinations and those with at least one prior DBT examination by using multivariable logistic regression models. Results The DM group consisted of 99 582 DM examinations in 55 086 women (mean age, 57.3 years ± 11.6 [standard deviation]). The DBT group consisted of 205 048 examinations in 76 276 women (mean age, 58.2 years ± 11.2). There were no differences in the cancer detection rate (CDR) between DM and DBT groups (4.6-5.8 per 1000 examinations, P = .08 to P = .95). The highest CDR was observed with a woman's first DBT examination (6.1 per 1000 examinations vs 4.4-5.7 per 1000 examinations with at least one prior DBT examination, P = .001 to P = .054). Compared with the DM group, the DBT1 group had a lower abnormal interpretation rate (AIR) (adjusted odds ratio [AOR], 0.85; P < .001), which remained reduced in the DBT2, DBT3, and DBT5 groups (P < .001 to P = .02). The reduction in AIR was also sustained after the first examination (P < .001 to P = .002). Compared with the DM group, the DBT1 group had a higher specificity (AOR, 1.20; P < .001), which remained increased in DBT2, DBT3, and DBT5 groups (P < .001 to P = .004). The increase in specificity was also sustained after the first examination (P < .001 to P = .01). Conclusion The benefits of reduced false-positive examinations and higher specificity with screening tomosynthesis were sustained after the first screening round at the individual level. © RSNA, 2020 See also the editorial by Taourel in this issue.

Reliability of Tablet-based Hearing Testing in Nicaraguan Schoolchildren: A Detailed Analysis.

Determine whether an electronic tablet-based Wireless Automated Hearing-Test System can perform high-quality audiometry to assess schoolchildren for hearing loss in the field in Nicaragua. Cross-sectional. A school and hospital-based audiology clinic in Jinotega, Nicaragua. Second and third graders (n = 120) were randomly selected for hearing testing in a school. Air conduction hearing thresholds were obtained bilaterally using a Wireless Automated Hearing-Test System at 1000, 2000, and 4000 Hz. Referral criteria were set at more than 25 dBHL at one or more frequencies. A cohort of children was retested with conventional audiometry in a hospital-based sound booth. Factors influencing false-positive examinations, including ambient noise and behavior, were examined. All children with hearing loss were detected using an automated, manual, or two-step (those referred from automated testing were tested manually) protocol in the school (sensitivity = 100%). Specificity was 76% for automated testing, 97% for manual testing, and 99% for the two-step protocol. The variability between thresholds obtained with automated testing was greater than manual testing when compared with conventional audiometry. The percentage of participant responses when no stimulus tone was presented during automated testing was higher in children with false-positive examinations. A Wireless Automated Hearing-Test System identified all children with hearing loss in a challenging field setting. A two-step protocol (those referred from automated testing are tested manually) reduced false-positive examinations and unnecessary referrals. Children who respond frequently when no tone is presented are more likely to have false-positive automated examinations and should be tested manually.

Long-Term Outcomes and Cost-Effectiveness of Breast Cancer Screening With Digital Breast Tomosynthesis in the United States.

Digital breast tomosynthesis (DBT) is increasingly being used for routine breast cancer screening. We projected the long-term impact and cost-effectiveness of DBT compared to conventional digital mammography (DM) for breast cancer screening in the United States. Three Cancer Intervention and Surveillance Modeling Network breast cancer models simulated US women ages 40 years and older undergoing breast cancer screening with either DBT or DM starting in 2011 and continuing for the lifetime of the cohort. Screening performance estimates were based on observational data; in an alternative scenario, we assumed 4% higher sensitivity for DBT. Analyses used federal payer perspective; costs and utilities were discounted at 3% annually. Outcomes included breast cancer deaths, quality-adjusted life-years (QALYs), false-positive examinations, costs, and incremental cost-effectiveness ratios (ICERs). Compared to DM, DBT screening resulted in a slight reduction in breast cancer deaths (range across models 0-0.21 per 1000 women), small increase in QALYs (1.97-3.27 per 1000 women), and a 24-28% reduction in false-positive exams (237-268 per 1000 women) relative to DM. ICERs ranged from $195026 to $270135 per QALY for DBT relative to DM. When assuming 4% higher DBT sensitivity, ICERs decreased to $130533-$156624 per QALY. ICERs were sensitive to DBT costs, decreasing to $78731 to $168883 and $52918 to $118048 when the additional cost of DBT was reduced to $36 and $26 (from baseline of $56), respectively. DBT reduces false-positive exams while achieving similar or slightly improved health benefits. At current reimbursement rates, the additional costs of DBT screening are likely high relative to the benefits gained; however, DBT could be cost-effective at lower screening costs.

Baseline Mammography: What Is It and Why Is It Important? A Cross-Sectional Survey of Women Undergoing Screening Mammography

ObjectivesStudies have shown that having a baseline mammogram, the first screening mammogram, available for comparison at the time of interpreting a subsequent mammogram significantly decreases the potential of a false-positive examination. Our aim was to evaluate knowledge of and perception about the significance of baseline mammograms in those women undergoing screening mammography. Materials and MethodsA cross-sectional prospective survey study was conducted in women without a history of breast cancer presenting for their screening mammogram. Respondents were surveyed anonymously between March and April 2017. The questionnaire was developed by primary care providers and radiologists and pretested for readability and clarity. ResultsIn all, 401 women (87% white, 93% educated beyond high school) completed surveys in which 77% of women reported having yearly mammograms, 31% reported having a history of an abnormal mammogram, and 45% had not heard the term baseline mammogram. Of those who had heard the term, the most commonly reported source was their primary care provider (31%). Although 74% chose the correct definition of a baseline mammogram, 67% did not think that a baseline mammogram was important for decreasing associated cost, time, and discomfort due to the number of mammograms incorrectly read as abnormal. ConclusionIn a group of educated women who routinely get mammograms, almost one-half had not heard the term baseline mammogram. Furthermore, most women did not think baseline mammography was important for decreasing associated cost, time, and discomfort due to mammograms incorrectly read as abnormal. This study suggests that efforts to improve women’s understanding of baseline mammograms and their importance are warranted, with greatest opportunity for health care providers and radiologists.

Diagnostic Performance of Ultrasonography for Pediatric Appendicitis: A Night and Day Difference?

For imaging pediatric appendicitis, ultrasonography (US) is preferred because of its lack of ionizing radiation, but is limited by operator dependence. This study investigates the US diagnostic performance during night shifts covered by radiology trainees compared to day shifts covered by attending radiologists. Appy-Scores (1 = completely visualized normal appendix; 2 = partially visualized normal appendix; 3 = nonvisualized appendix with no inflammatory changes in the expected region of the appendix; 4 = equivocal; 5a = nonperforated appendicitis; 5b = perforated appendicitis) from 2935 US examinations (2161:774, day-to-night) from July 2013 to 2014 were correlated with the intraoperative diagnoses and the clinical follow-up. The diagnostic performance of trainees and attendings was compared with Fisher exact test. Interobserver agreement was measured by Cohen kappa coefficient. Appendicitis prevalence was 25.3% (day) and 22.5% (night). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive vale were 94.0%, 93.7%, 93.8%, 97.9%, and 83.4% during the day and 92.0%, 91.2%, 91.3%, 97.5%, and 75.2% at night. Specificity (P = .048) and positive predictive value (P = .011) differed, with more false positives at night (7%) than during the day (4.7%). Trainee and attending agreement was high (k = 0.995), with Appy-Scores of 1, 4, and 5a most frequently discordant. US has a high diagnostic performance and interobserver agreement for pediatric appendicitis when interpreted by radiology trainees during night shifts or attending radiologists during day shifts. However, lower specificity and positive predictive value at night warrants a thorough trainee education to avoid false-positive examinations.

Late cardiac tamponade after cardiac trauma: A case report and a review

The pericarditis is an inflammation process of the pericardium with lots of causes, primary and secondary. It may progress with pericardial effusion and/or constrictive pericarditis. The presentation as late cardiac tamponade due to trauma is a rare clinical condition and may occur days or weeks after trauma. We report a case observed in a trauma hospital of Manaus-Amazonas, Brazil periphery. The patient presented to the hospital 18 days after a chest trauma with signs and symptoms of cardiac tamponade: tachycardia, turgid jugular veins, inferior limbs swollen, presenting breathing difficulties, and supine position not tolerated. He underwent exploratory thoracotomy, and a thick pericardium with purulent effusion was found. It is important to suspect cadiac injury in patients who are victims of trauma on cardiac box, to observe that the focused assessment sonography for trauma is used, but it has its limitations. It is 90%–95% accurate for the presence of pericardial fluid for the experienced operator. Concomitant hemothorax may account for both false-positive and false-negative ultrasound examinations.[2] When necessary, the subxiphoid exploration must be done. The possibility of occult cardiac lesion or silent cardiac wound should always be considered in patients with chest trauma by knife or gunshot on Zieddler area or cardiac box, to prevent a late cardiac tamponade or pericarditis.

Effectiveness of Digital Breast Tomosynthesis Compared With Digital Mammography: Outcomes Analysis From 3 Years of Breast Cancer Screening.

Breast cancer screening with digital breast tomosynthesis (DBT) combined with digital mammography (DM) decreases false-positive examinations and increases cancer detection compared with screening with DM alone. However, the longitudinal performance of DBT screening is unknown. To determine whether the improved outcomes observed after initial implementation of DBT screening are sustainable over time at a population level and to evaluate the effect of more than 1 DBT screening at the individual level. Retrospective analysis of screening mammography metrics was performed for all patients presenting for screening mammography in an urban, academic breast center during 4 consecutive years (DM, year 0; DBT, years, 1-3). The study was conducted from September 1, 2010, to September 30, 2014 (excluding September 2011, which was the transition period from DM to DBT), for a total of 44 468 screening events attributable to a total of 23 958 unique women. Differences in screening outcomes between each DBT year and the DM year, as well as between groups of women with only 1, 2, or 3 DBT screenings, were assessed, and the odds of recall adjusted for age, race/ethnicity, breast density, and prior mammograms were estimated. Data analysis was performed between February 16 and October 26, 2015. Digital mammography screening supplemented with DBT. Recall rates, cancer cases per recalled patients, and biopsy and interval cancer rates were determined. Screening outcome metrics were evaluated for a total of 44 468 examinations attributable to 23 958 unique women (mean [SD] age, 56.8 [11.0] years) over a 4-year period: year 0 cohort (DM0), 10 728 women; year 1 cohort (DBT1), 11 007; year 2 cohort (DBT2), 11 157; and year 3 cohort (DBT3), 11 576. Recall rates rose slightly for years 1 to 3 of DBT (88, 90, and 92 per 1000 screened, respectively) but remained significantly reduced compared with the DM0 rate of 104 per 1000 screened. Reported as odds ratios (95% CIs), the findings were DM vs DBT1, 0.83 (0.76-0.91, P < .001); DM vs DBT2, 0.85 (0.78-0.93, P < .001); and DM vs DBT3, 0.87 (0.80-0.95, P = .003). The cancer cases per recalled patients continued to rise from DM0 rate of 4.4% to 6.2% (P = .06), 6.5% (P = .03), and 6.7% (P = .02) for years 1 to 3 of DBT, respectively. Outcomes assessed for the most recent screening for individual women undergoing only 1, 2, or 3 DBT screenings during the study period demonstrated decreasing recall rates of 130, 78, and 59 per 1000 screened, respectively (P < .001). Interval cancer rates, determined using available follow-up data, decreased from 0.7 per 1000 women screened with the use of DM to 0.5 per 1000 screened with the use of DBT1. Digital breast tomosynthesis screening outcomes are sustainable, with significant recall reduction, increasing cancer cases per recalled patients, and a decline in interval cancers.

Rethinking Preoperative Breast Magnetic Resonance Imaging.

Although magnetic resonance imaging (MRI) is exquisitely sensitive for detecting breast cancer, its precise clinical benefit in the routine preoperative setting is uncertain, and determinationof itsappropriateuse todatehasbeenchallenging.1 Early randomized prospective trials were hindered by low numbers, wide variation in imaging quality, and inconsistencies in incorporating MRI findings into treatment planning. Larger, more recent, retrospective trialshave reportedcorrelationsbetweenuseofbreast MRI and increased mastectomy rates but have been significantly limited by not controlling for key variables that are independentlyassociatedwithmastectomyrates.2-4Womenwho undergo preoperative MRI comprise a distinct subset of patients: theyaremore likely tobeyoung, athigh risk,havedense breast tissue, have genetic mutations, have more aggressive tumor subtypes, be seen at academic subspecialized centers thatoffer advanced reconstructive surgical techniques, andbe in ahigher socioeconomic status group than thosewhodonot undergo MRI. These factors themselves are known to be associatedwith higher rates ofmastectomies2,5; thus, failure to control for these variables is a significant limitation of retrospective studies seekingmeaningful correlationsbetweenMRI use and outcomes. Most important, correlation does not imply causation. In this issueof JAMAOncology, Arnaout et al6 evaluate the utilization of preoperative breast MRI. Using a populationbased cancer registry in Ontario, Canada, to identify incident breast cancers in thepreoperative setting, the authors6 found that preoperative MRI was performed in less than 15% of all patients diagnosed ashavingbreast cancer. The authors6 confirmedwhatothershavereported:womenwhounderwentpreoperative breast MRI were more likely to be young, at higher socioeconomic status, anddiagnosedashaving invasive lobular cancers at higher stage comparedwithwomenwhodidnot receive MRI. Patients seen at teaching hospitals or by surgeonswithhighervolumeswhomorerecentlycompletedtraining were more likely to undergo breast MRI. They6 also found differences in short-term surgical outcomesbetweenpatientswhounderwentbreastMRIand those who did not, including longer wait-times between diagnosis and surgery, higher rates of additional imaging and/or biopsies prior to surgery, and higher rates of ipsilateral and contralateralprophylacticmastectomy.Recognizingthat theseoutcomes aredependent onpatient, surgeon, and systemfactors, the authors6 controlled for some variables, such as socioeconomic status, age, tumor histologic type, patient comorbidity, surgeon experience, and the environment (academic vs community-basedpractice) inwhichapatientwas treated.Unfortunately, theauthorswerenotable tocontrol forgeneticmutation status, family history, or breast density. The authors6 suggest that rising breastMRIuse inwomen newly diagnosed as having breast cancer may contribute to a general problem of breast cancer overtreatment by prompting unnecessary additional imaging tests, biopsies, andmastectomies either in the affected breast or the unaffected contralateral breast. Because abnormalities identified on breast MRI require samplingprior todefinitive treatment, it isnot surprising that preoperative breastMRI prompts additional tests and biopsies, which in turn can lead to longer wait times between diagnosis and surgery. Furthermore, because MRI detectsmammographicallyoccultmulticentricdisease in roughly 10% of patients, and mastectomy is currently indicated for women with multicentric disease, it is logical that mastectomy rates would rise with its use. Finally, it is reasonable to believe that additional procedures resulting from falsepositive examinations could result in higher patient anxiety, tipping the scales toward more mastectomies. However, it is important to interpret the outcomes associatedwithobtainingpreoperative breastMRI from this study with some caution. Because the authors6 did not report MRI results (eg, if the MRI was interpreted as positive or negaRelated article page 1238 Opinion Editorial

Increased Risk of Developing Breast Cancer after a False-Positive Screening Mammogram.

Women with a history of a false-positive mammogram result may be at increased risk of developing subsequent breast cancer. Using 1994 to 2009 Breast Cancer Surveillance Consortium data, we included women ages 40 to 74 years with a screening mammogram that resulted in a false-positive with recommendation for additional imaging, false-positive with recommendation for biopsy, or true-negative with no cancer within one year following the examination. We used partly conditional Cox proportional hazards survival models to assess the association between a false-positive mammogram result and subsequent breast cancer, adjusting for potential confounders. Adjusted survival curves stratified by breast density and false-positive result were used to evaluate changes in risk over time. During 12,022,560 person-years of follow-up, 48,735 cancers were diagnosed. Compared with women with a true-negative examination, women with a false-positive with additional imaging recommendation had increased risk of developing breast cancer [adjusted HR (aHR) = 1.39; 95% confidence interval (CI), 1.35-1.44] as did women with a false-positive with a biopsy recommendation (aHR = 1.76; 95% CI,1.65-1.88). Results stratifying by breast density were similar to overall results except among women with almost entirely fatty breasts in which aHRs were similar for both the false-positive groups. Women with a false-positive result had persistently increased risk of developing breast cancer 10 years after the false-positive examination. Women with a history of a false-positive screening mammogram or biopsy recommendation were at increased risk of developing breast cancer for at least a decade, suggesting that prior false-positive screening may be useful in risk prediction models.

Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society.

Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality. To update the American Cancer Society (ACS) 2003 breast cancer screening guideline for women at average risk for breast cancer. The ACS commissioned a systematic evidence review of the breast cancer screening literature to inform the update and a supplemental analysis of mammography registry data to address questions related to the screening interval. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health. Estimates of the cumulative lifetime risk of false-positive examination results are greater if screening begins at younger ages because of the greater number of mammograms, as well as the higher recall rate in younger women. The quality of the evidence for overdiagnosis is not sufficient to estimate a lifetime risk with confidence. Analysis examining the screening interval demonstrates more favorable tumor characteristics when premenopausal women are screened annually vs biennially. Evidence does not support routine clinical breast examination as a screening method for women at average risk. The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation). These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer. These recommendations should be considered by physicians and women in discussions about breast cancer screening.

Can adding contrast-enhanced digital mammography (CEDM) as an adjunct to diagnostic mammography/US help decrease biopsy rates in women with suspicious (BIRADS 4) breast lesions?

6 Background: Traditional screening mammography (MG) enables early detection of breast cancer and therefore results in decreased mortality. Mammography, however, is an imperfect tool and limited by an overall sensitivity of 75-85%. Specificity is limited as well resulting in many false-positive examinations and unnecessary follow-up examinations. The recent development of contrast-enhanced digital mammography (CEDM) has made the usage of IV contrast enhancement with mammography a possibility. CEDM is an angiographic technique that uses digital subtraction, which removes the normal mammary gland on images in order to detect breast tumors and visualize their vascularity. The literature is promising with regard to CEDM as studies have found that CEDM achieves increased sensitivity without reductions in specificity in comparison to MG, US and/or MRI. Methods: In this multi-reader study we compared the diagnostic accuracy of CEDM as an adjunct to MG/US in patients with suspicious findings (BI-RADS 4). The study population included 31 patients who were imaged with CEDM prior to their scheduled US or stereotactic-guided biopsy. We compared the relative performance of MG/US alone versus MG/US/CEDM in determining the probability of malignancy. Histology served as the gold standard. Results: See table below. Conclusions: The addition of CEDM to the workup of suspected lesions on MG and/or US preliminarily decreases the number of false-positive MG thereby with potential to reduce cost and unnecessary patient harm. [Table: see text]