Routine Breast Cancer Screening Research Articles

Computer-aided detection mammography for breast cancer screening: systematic review and meta-analysis

Mammography is generally accepted as the best available breast cancer screening method; however, some cancers detectable on mammography images are missed. Computer-aided detection (CAD) systems for mammography are intended to reduce false negatives by marking suspicious areas of the mammograms for reviewers to consider. Although the prospect of improving the sensitivity of screening mammograms has led to the diffusion of CAD for mammography, little is known about its diagnostic accuracy. To assess the diagnostic performance of CAD for screening mammography in terms of sensitivity and specificity and incremental recall, biopsy, and cancer diagnosis rates. Published literature identified by systematic literature searches of 17 databases, including MEDLINE, EMBASE, and the Cochrane Library, searched through 25 September 2008. A reviewer and an information specialist selected full-length English-language articles that enrolled asymptomatic women for routine breast cancer screening and provided data needed for our analyses using criteria established a priori. We identified 75 potentially relevant publications, of which 7 (9%) were included. Data were extracted and internal validity was assessed by a single review author, and forms were approved by the co-authors. Three studies (n = 347,324) reported sensitivity and specificity, or data to calculate them, and five studies (n = 51,162) reported data to calculate incremental rates of cancer diagnoses and recall and biopsy of women who did not have breast cancer. The pooled sensitivity was 86.0% (95% CI 84.2-87.6%) and specificity was 88.2% (95% CI 88.1-88.3%). Of the 100,000 women screened, CAD yielded an additional 50 (95% CI 30-80) correct breast cancer diagnoses, 1,190 (95% CI 1,090-1,290) recalls of healthy women, and 80 (95% CI 60-100) biopsies of healthy women. A total of 96% (95% CI 93.9-97.3%) of women recalled based upon CAD and 65.1% (95% CI 52.3-76.0%) of women biopsied based upon CAD were healthy. No studies reported patient-oriented clinical outcomes.

Breast and Cervical Cancer Screening Practices among Disabled Women Aged 40–75: Does Quality of the Experience Matter?

Women with disabilities (WWD) face significant barriers accessing healthcare, which may affect rates of routine preventive services. We examined the relationship between disability status and routine breast and cervical cancer screening among middle-aged and older unmarried women and the differences in reported quality of the screening experience. Data were from a 2003-2005 cross-sectional survey of 630 unmarried women in Rhode Island, 40-75 years of age, stratified by marital status (previously vs. never married) and partner gender (women who partner with men exclusively [WPM] vs. women who partner with women exclusively or with both women and men [WPW]). WWD were more likely than those without a disability to be older, have a high school education or less, have household incomes <$30,000, be unemployed, and identify as nonwhite. In addition, WWD were less likely to report having the mammogram or Pap test procedure explained and more likely to report that the procedures were difficult to perform. After adjustment for important demographic characteristics, we found no differences in cancer screening behaviors by disability status. However, the quality of the cancer screening experience was consistently and significantly associated with likelihood of routine cancer screening. Higher quality of cancer screening experience was significantly associated with likelihood of having routine breast and cervical cancer screening. Further studies should explore factors that affect quality of the screening experience, including facility characteristics and interactions with medical staff.

Racial and ethnic differences in mammography use among U.S. women younger than age 40

Evidence-based recommendations for routine breast cancer screening suggest that women begin mammography at age 40, although some women receive a mammogram before that age. Little is known about mammography use among younger women, especially with respect to race and ethnicity. We used data from the 2005 National Health Interview Survey to examine racial/ethnic differences in mammography use among U.S. women ages 30-39. We examined descriptive characteristics of women who reported ever having a mammogram, and used logistic regression to estimate associations between race/ethnicity and mammography use among women at average risk for breast cancer. Our sample comprised 3,098 women (18% Hispanic, 13% non-Hispanic [NH] black, 69% NH white), of whom 29% reported having ever had a mammogram. NH black women were more likely than NH white women to report ever having a mammogram and receiving multiple mammograms before age 40 among women of average risk. Patterns of mammography use for Hispanic women compared to NH white women varied. Findings suggest differential utilization of mammograms by race/ethnicity among women outside current recommendations and of average risk. Future studies should examine the role of practice patterns and patient-provider communication.

Editorial: Gene Expression Profile Assays As an Aid in Treatment Decision Making in Early-Stage Breast Cancer

Each year, more than 200,000 women in the United States are diagnosed with invasive breast cancer, and approximately 40,000 die from the disease.1 Nearly half of these women present with hormone receptor–positive, lymph node– negative disease, a subgroup that has increased in size due largely to routine breast cancer screening and increased awareness. Currently, the decision to treat early-stage breast cancer with adjuvant chemotherapy and hormonal therapy is based on clinical and histologic criteria including tumor size, grade, hormone receptor status, human epidermal growth factor receptor (HER-2)/neu overexpression, and the presence or absence of lymph node involvement. Patient menopausal status may affect treatment decisions due to presumed lower recurrence risk and both smaller benefit and greater toxicity with systemic chemotherapy in older women. Clinical practice guidelines recommend adjuvant chemotherapy as well as hormonal therapy for most women with hormone receptor–positive, lymph node– negative early-stage breast cancer. However, the majority of women with hormone receptor–positive lymph node–negative, breast cancer do not develop distant recurrence or death even in the absence of adjuvant chemotherapy. In addition, systemic chemotherapy is associated with both immediate and delayed toxicity, as well as considerable cost.2,3 At the same time, randomized controlled trials have shown that adjuvant chemotherapy is beneficial in some women with early-stage breast cancer, while others will develop distant metastases despite receiving chemotherapy.4 Many breast cancer patients therefore continue to be either overtreated or undertreated with adjuvant chemotherapy due to the lack of sufficiently accurate prognostic and predictive information. The availability of high-performance screening techniques using DNA microarrays has permitted analysis of gene expression patterns and study of their relationship to the risk of disease recurrence as well as treatment effectiveness, in an effort to guide clinicians in their daily decisions on the use of systemic adjuvant therapy.

SU-FF-J-116: Image Registration for Change Detection and Quatification in Multimodality Breast Tomosynthesis and Ultrasound

Purpose: To evaluate tomosynthesis‐to‐tomosynthesis and ultrasound‐to‐ultrasound image based registration (IBaR) of whole breast image volumes acquired at different times. These two modalities are probably the most immediately promising for routine breast cancer screening and diagnosis. Successful IBaR should aid more rapid and detailed detectio of change in response to treatment or tumor growth over time. Method and Materials: A system combining automated whole breast ultrasound (ABU) and digital tomosynthesis mammography(DTM) is being utilized in several studies of breast mass classification and assessment of response to neoadjuvant chemotherapy. Much attention was given to making the breast stable for the duration of each exam with the breast compressed between mammographic‐style plates and with acoustic coupling for reproducible, large area scanning through the plates. Four DTM pairs and many ABU pairs were acquired after reasonable stability and coverage techniques were developed. Registration was performed with MIAMI Fuse™ nonrigid registration based on the mutual information cost function and thin plate spline interpolation.Results: Registration was successful on 5 of 8 recent ABU image volume pairs with a mean registration error (MRE) of 3±2 mm and on all 4 DTM pairs, MRE = 4 ± 2 mm, as determined from visually selected homologous points. The lowest DTM mean error was obtained from studies 1 year apart, with minimal change in the breast. Conclusion: Both ABU and DTM offer angle dependent artifacts, with registration being perhaps more difficult in ABU. The variable breast distortion during compression offers similar difficulties, probably greater than actual breast change. No special effort was directed toward reproducible positioning. These results suggest that, usually, it should be possible to display in the same slice of two separate studies, a breast mass of > 5 mm, or its preceding tissues. Conflict of Interest: Work performed in cooperation with xxx, Inc.

Comparison of a New and Existing Method of Mammographic Density Measurement: Intramethod Reliability and Associations with Known Risk Factors

Mammographic density is one of the strongest risk factors for breast cancer. It is commonly measured by an interactive threshold method that does not fully use information contained in a mammogram. An alternative fully automated standard mammogram form (SMF) method measures density using a volumetric approach. We examined between-breast and between-view agreement, reliability, and associations of breast cancer risk factors with the threshold and SMF measures of breast density on the same set of 1,000 digitized films from 250 women who attended routine breast cancer screening by two-view mammography in 2004 at a London population-based screening center. Data were analyzed using random-effects models on transformed percent density. Median (interquartile range) percent densities were 12.8% (5.0-22.3) and 21.8% (18.4-26.6) in the threshold and SMF methods, respectively. There was no evidence of systematic differences between left-right breasts or between views in either method. Reliability of a single measurement was lower in the SMF than in the threshold method (0.77 versus 0.92 for craniocaudal and 0.68 versus 0.89 for mediolateral oblique views). Increasing body mass index and parity were associated with reduced density in both methods; however, an increase in density with hormone replacement therapy use was found only with the threshold method. Established properties of mammographic density were observed for SMF percent density; however, this method had poorer left-right reliability than the threshold method and has yet to be shown to be a predictor of breast cancer risk.

Tumor susceptibility and prognosis of breast cancer associated with the G870A polymorphism of CCND1

We aimed to investigate the role of CCND1 G870A polymorphism genetic and transcriptomic effects susceptibility in association with breast cancer carcinogenesis and clinical prognosis. A case-control study was conducted with the enrollment of 992 sporadic breast cancer patients and the corresponding 960 normal controls from routine mammographic or sonographic screening for breast cancer between 1995 and 2003 in Taiwan. The 167 fragment spanning the G870A polymorphism in exon 4-intron 4 boundary was amplified to identify genotype of CCND1 (G870A) polymorphism. Competitive RT-PCR were further performed to investigate alternative transcript in four different specimens in association with immunohistochemistry markers. The results showed that AG and AA subgroup were at increased risk for developing breast cancer compared with the GG genotype by 19% (OR 1.19 (0.85-1.67)) and by 34% (OR 1.34 (0.04-1.74)), respectively. A870 allele revealed a recessive tendency while GG and AA/AG subgroup was compared (OR 1.35 (1.07-1.70)). AA genotype also had a higher risk in premenopausal women than postmenopausal ones. The recurrence-free survival was longer in patients with GG+AG than that in patients with AA (P = 0.034). A870 allele produced more transcript b both in malignant. There were significant correlations between several immunohistochemistry markers (such as Ki-67) and cyclin D1 or CDk4. We concluded CCND1 G870A polymorphism make significant contribution to breast cancer in the country with the preponderance of breast cancer in young women. The role of G870A polymorphism in alternative transcript was not only implicated in CCND1 alternative splicing but also correlated with immunohistochemistry markers.

Considerations in Retransplantation of the Failed Renal Allograft Recipient

Routine success in kidney transplantation has significantly improved the quality and length of life for the majority of recipients and made this option the treatment of choice for suitable candidates. Improved patient survival combined with a relative static improvement in long-term graft outcomes has led to an increasing number of transplant recipients with failed allografts who face the eventual option of either returning to dialysis or seeking retransplantation. Although retransplantation is presumed to be a favorable option for many, data to support this belief is limited. Given the wide variance in predicted outcomes for retransplantation, on the basis of the underlying kidney disease and other individual patient comorbidities as well as the expected wait time for a second transplant, each case should be evaluated independently. This review discusses available data and individual considerations that should be taken into account when retransplantation is proposed after failure of a primary allograft.

Understanding locally advanced breast cancer: What influences a woman's decision to delay treatment?

Background Despite early detection having been identified as a key factor in long-term survival of patients with breast cancer, women with locally advanced breast cancer continued to present at many medical centers. Methods Women with locally advanced breast cancer (LABC) ( N = 11) and matched controls ( N = 11) with Stage I or II breast cancer completed semi-structured interviews and the Hospital Anxiety and Depression Scale, Life Orientation Test, Multidimensional Health Locus of Control Scale, Body Investment Scale, Monitor-Blunter Style Scale, and Religious Coping Scale. Five spouses of the LABC group and eight control partners were similarly assessed. Results On psychological tests, no significant differences were found between patient groups; however, LABC spouses reported significantly greater active religious surrender ( t = 2.37, P = 0.037) and depression ( t = 3.54, P = 0.047) than control spouses. The women’s semi-structured interviews identified that LABC was associated with inattention to routine breast cancer screening, denial, fatalism and reliance on alternative therapies. Spouses of the LABC group tended to be more passive in their wives’ medical care, and also utilized fatalistic thinking and denial. Conclusions It is important for health care providers to identify patients who will require extra encouragement to seek timely medical care and to follow through with treatment recommendations.

Hormone replacement therapy and false positive recall in the Million Women Study: patterns of use, hormonal constituents and consistency of effect

IntroductionCurrent and recent users of hormone replacement therapy (HRT) have an increased risk of being recalled to assessment at mammography without breast cancer being diagnosed ('false positive recall'), but there is limited information on the effects of different patterns of HRT use on this. The aim of this study is to investigate in detail the relationship between patterns of use of HRT and false positive recall.MethodsA total of 87,967 postmenopausal women aged 50 to 64 years attending routine breast cancer screening at 10 UK National Health Service Breast Screening Units from 1996 to 1998 joined the Million Women Study by completing a questionnaire before screening and were followed for their screening outcome.ResultsOverall, 399 (0.5%) participants were diagnosed with breast cancer and 2,629 (3.0%) had false positive recall. Compared to never users of HRT, the adjusted relative risk (95% CI) of false positive recall was: 1.62 (1.43–1.83), 1.80 (1.62–2.01) and 0.76 (0.52–1.10) in current users of oestrogen-only HRT, oestrogen-progestagen HRT and tibolone, respectively (p (heterogeneity) < 0.0001); 1.65 (1.43–1.91), 1.49 (1.22–1.81) and 2.11 (1.45–3.07) for current HRT used orally, transdermally or via an implant, respectively (p (heterogeneity) = 0.2); and 1.84 (1.67–2.04) and 1.75 (1.49–2.06) for sequential and continuous oestrogen-progestagen HRT, respectively (p (heterogeneity) = 0.6). The relative risk of false positive recall among current users appeared to increase with increasing time since menopause, but did not vary significantly according to any other factors examined, including duration of use, hormonal constituents, dose, whether single- or two-view screening was used, or the woman's personal characteristics.ConclusionCurrent use of oestrogen-only and oestrogen-progestagen HRT, but not tibolone, increases the risk of false positive recall at screening.

Simulation modeling of change to breast cancer detection age eligibility recommendations in Ontario, 2002–2021

Purpose: The purpose of this project was to demonstrate the development and use of a decision support tool based on simulation modeling of breast cancer screening to evaluate the implications for the provision of health services and the economic impact of extending routine radiographic screening for breast cancer to women in the 40–49 age group between 2002 and 2021. Methods: The main method was computer simulation with a Markov model that used published estimates of population size by age group, breast cancer prevalence and incidence, screening program participation rate, sensitivity and specificity of the screening test and diagnostic test, stage transition probabilities, directed diagnosis rates and costs. Findings: The model predicted that changes to age eligibility requirements would result in the detection of an additional 6610 women with breast cancer in Ontario requiring treatment, at an additional cost of CAN$ 795 per case. These costs include those related to screening, diagnosis and initial treatment and apply to the 20-year period. Conclusions: The model provided a useful decision support tool for those planning and implementing breast cancer screening programs.

The Attack on Breast Cancer Screening

The Attack on Breast Cancer Screening

Hormone replacement therapy and the sensitivity and specificity of breast cancer screening: a review.

The use of hormone replacement therapy (HRT) is prevalent in the age group invited to routine breast cancer screening in many countries. Previous publications have reported reduced sensitivity and specificity of mammographic breast cancer screening associated with current use of HRT. To review the epidemiological evidence for the relation between use of HRT and the risk of having breast cancer diagnosed between screens (interval breast cancer--sensitivity) and being recalled for assessment after initial mammography with no diagnosis of breast cancer at that screen (false positive recall--specificity). Overview of published literature. Eight studies were identified, providing a total of 367 interval cancers and 8878 cases of false positive recall, in women of 50 and over. Overall, the studies showed an increased risk of interval cancer and false positive recall in current users of HRT compared with non-users. Only one study accounted for the essential confounding factors of age and menopause. Furthermore, information on duration and recency of HRT use was not available for most studies. Studies to date indicate that women using HRT are more likely to experience reduced sensitivity and specificity of breast cancer screening, compared with women not using HRT. However, because results have not been adjusted for crucial confounding factors, the magnitude of these effects is uncertain.

The Million Women Study: design and characteristics of the study population. The Million Women Study Collaborative Group.

To describe the design of the Million Women Study and the characteristics of the study population. Population-based cohort study of women aged 50-64 in the UK. Women are asked to join the Million Women Study when they are invited to routine screening for breast cancer at 61 of the screening centres of the UK National Health Service Breast Screening Programme (NHSBSP). An estimated 71% of women screened by the NHSBSP return a completed questionnaire. 800 000 women were recruited between May 1996 and June 1999, and it is planned that an additional 200 000 will be recruited by the year 2000. The characteristics of the first 121 000 women recruited into the Million Women Study are described here. At recruitment 33% of the study population were currently using hormone replacement therapy and 47% had used it at some time. Over half (54%) had used oral contraceptives, and 18% were current smokers at the time of recruitment. Before they were screened 1.4% of the women had been diagnosed with breast cancer in the past, 6% had a mother with a history of breast cancer and 3.7% had a sister with a history of breast cancer. It is estimated that 1 million women will have been recruited by early in the year 2000, and that by the end of the year 2002 there will be 5000 screen-detected breast cancers and 23 000 deaths in the cohort, the majority of which will be attributed to cancer (12 600 deaths) and circulatory disease (8000 deaths). By the end of the year 2002, the Million Women Study will have sufficient statistical power to detect relative risks of 0.8 or less, or of 1.2 or more in current users compared with never users of hormone replacement therapy for mortality from breast cancer, colorectal cancer, lung and ovarian cancer, ischaemic heart disease and stroke.

Are there any indications for routine breast cancer screening of asymptomatic women who are less than 40 years old?

Are there any indications for routine breast cancer screening of asymptomatic women who are less than 40 years old?

Breast cancer screening in younger women: evidence and decision making.

Contrasting conclusions on the efficacy of routine breast cancer screening in younger women, under age 50, have been produced by expert and influential groups, particularly in the United States. In an international workshop in 1993, and again at a consensus development conference in 1997, the National Institutes of Health and the National Cancer Institute concluded that evidence for efficacy was uncertain, and routine screening could not be recommended. The 1997 conference concluded that the individual decision had to be made by each woman and her health care provider. In contrast, the American Cancer Society has advocated routine screening, despite accepting that the randomized trial evidence does not clearly support it. The decision of the 1997 NCI consensus conference has been rejected by the director of the NCI, and a similar controversy occurred in 1993. On two occasions, US Senate subcommittees have affirmed support for screening and criticized the conclusions of expert groups. In this paper, the arguments raised in these discussions, and the differing ways in which scientific evidence has been assessed, are discussed.

Other Voices Weigh In on Mammography Decision

IN YET another attempt to resolve the controversy over when women their 40s should be recommended to undergo routine mammographic screening for breast cancer, the advisory board of the National Cancer Institute (NCI) has set up a subcommittee charged with preparing a set of recommendations intended to help making the difficult choice about whether and when to have a mammogram. From the comments at a press conference held after the board's decision, what will probably emerge is individualized advice, not blanket recommendations. There are unlikely to be firm, definitive guidelines on precisely when to start routine mammographic screening. This result will not satisfy those who want clear-cut answers or third-party payers unwilling to reimburse for any procedure without authoritative evidence of its value. The subcommittee's recommendations will be completed in a timely manner, the next couple of months before the board meets June, said Barbara K.

Film screen mammography and sonography in the evaluation of breast prosthesis integrity : Scott Soo M, Sullivan DC, Hooper D, et al. (Duke University Medical Center, Department of Radiology, P.O. Box 3808, 2nd Floor, Hospital South, Durham, NC 27710). Breast Dis 1996;9:81–92

The purpose of this study was to determine the sensitivity and specificity of film screen mammography and sonography in detecting implant rupture and identify findings significantly associated with rupture. The sensitivity and specificity of preoperative mammograms and sonograms performed on 139 consecutively removed implants were determined retrospectively from preoperative imaging reports. Mammograms and sonograms were then reviewed to identify findings associated with implant rupture. Multivariate and univariate analyses were performed with adjustments made for date of implant placement. The prevalence of rupture was 62%. Sensitivity and specificity from preoperative reports were 68% and 72% (individually, mammography 51% and 96%, respectively ; sonography 85% and 57%, respectively). Protrusions (smooth and irregular) were highly associated with rupture (p < 0.05). Extracapsular silicone was also associated with rupture (p < 0.1). The sonographic snowstorm pattern was significant in the univariate analysis. It was concluded that, although not as sensitive as MRI, mammography and sonography can demonstrate specific findings associated with ruptured implants. For patients with implants undergoing routine breast cancer screening, mammography and adjunctive sonography are still useful and readily available for detecting rupture.

Factors associated with Pap smear taking in general practice: focusing public health initiatives

This study ascertained the relationships of patient, practitioner and consultation factors with: 1. taking a Pap smear or referral to a specialist in the consultation; and 2. an unsuccessful offer to take a Pap smear or making an appointment for a smear. In a cross-sectional study of 3478 women presenting to 230 randomly selected general practitioners in Brisbane and Toowoomba, information about most recent Pap smear, screening in the consultation, and independent variables were collected from patients and doctors. Relationships between three levels of outcome variable (no action, Pap smear taken or referral, appointment or refusal), and independent variables (practitioner variables, consultation variables, patient variables) were modelled using polytomous logistic regression. Presenting for a routine checkup and breast cancer screening were associated with all types of action. Younger age, longer consultations and consultations with a female practitioner were associated with Pap smear taking and referrals, and not appointments or refusals. Being due for a Pap smear, having blood pressure measured, consulting a younger general practitioner and one who ascribed to current guidelines on screening were associated with an appointment or a refusal, when compared with no action. Results identify different profiles of those who get a Pap smear and those who do not, the former indicating a more proactive patient group, while the latter suggest more active general practitioners who attempted opportunistic screening of passive patients, or women who do not specifically seek Pap smears. We have identified factors that have significance for developing public health programs focused on consumers and providers.

Adherence to Cancer Screening.

Routine breast cancer screening for women 50 years of age and older can reduce mortality from breast cancer by 30% to 35%. Regular Papanicolaou tests can decrease mortality from cervical cancer dramatically, and skin cancer screening could decrease deaths from melanoma. Adherence to recommended screening procedures for breast, cervical, and skin cancer screening increases the potential to lower the risk of death and disability from these diseases. The National Cancer Institute's goals include increasing the proportion of women who get regular mammograms to 80%, and similar goals have been issued for Pap tests. Yet, most women still are not being screened for breast or cervical cancer on a regular basis, and most people do not have regular skin checks for cancer.