Supplemental Breast Cancer Screening Research Articles

Patient-Friendly Summary of the ACR Appropriateness Criteria: Supplemental Breast Cancer Screening Based on Breast Density.

Patient-Friendly Summary of the ACR Appropriateness Criteria: Supplemental Breast Cancer Screening Based on Breast Density.

Advances and Future Directions in Molecular Breast Imaging.

Molecular breast imaging (MBI) using 99mTc-sestamibi has advanced rapidly over the past decade. Technical advances allow lower-dose, higher-resolution imaging and biopsy capability. MBI can be used for supplemental breast cancer screening with mammography for women with dense breasts, as well as to assess neoadjuvant therapy response, evaluate disease extent, and predict breast cancer risk. This article highlights the current state of the art and future directions in MBI.

The cut-off value of ADC to differentiate benign from malignant breast lesions

Background: Diffusion-weighted MRI is a fast, unenhanced modality that shows promise in identifying mammographically occult malignancy and warrants further investigation as an alternative supplemental breast cancer screening tool.Aim of study: To estimate the diagnostic accuracy of diffusion wighted imaging and apparent diffusion coeffient (ADC) value in the differentiation between benign and malignant breast lesions, and to obtain a cutoff ADC value between benign and malignant breast lesions along with histopathological correlation. Materials and Methods: A prospective study of 56 patients with present with breast mass who examined at 1.5 tesla MRI & proved by histopathology. ADC value were a quired at b values of 0, 600, 850 s/mm² after identification of ROI (Region of interest) placement. ADC value with histopathology correlation was analyzed. Results: From total 56 lesions, 24 lesions were histologically malignant and 32 were histologically benign. With an ADC cut‑off value of 1.31 × 10−3 mm2/s for malignant lesions, a sensitivity of 100% and specificity of 72.1% was obtained. The false‑postive lesions were one intraductal papilloma & 3 abcesses in which a low ADC value was obtained. Purely DCIS (Ductal carcinoma in situ) lesions presenting as non‑mass‑like enhancement had a high ADC value of 1.2‑1.3 × 10−3 mm2/s, thereby decreasing specificity. Conclusion: Diffusion‑weighted Imaging is a functionl quantitative assessment by ADC value, may act as an efficient tool in increasing the diagnostic accuracy and specificity of breast MRI in the characterization of different breast lesions.

Physicians' perceptions of breast density notification laws and appropriate patient follow-up.

Breast density notification laws have been adopted in the absence of consistent guidelines for post-notification follow-up. This can lead to inconsistent and potentially deficient management of women's health due to inconsistent physician practices. We examined physicians' knowledge and practices regarding follow-up for patients who receive density notifications. Physicians who referred patients to a Michigan hospital network for screening mammograms were recruited to participate in survey study; 105 (29.8%) responded. The survey assessed physicians' demographics, knowledge, and awareness of breast density and breast cancer risk and of density notification laws, and perceptions of appropriate follow-up behaviors for their patients who received density notifications. Most physicians (75%) knew about the notification law, and they were generally comfortable responding to breast density questions and deciding on follow-up. Most indicated that additional breast imaging (68.0%), followed by assessing breast cancer risk (24.7%) were appropriate follow-up responses. Physicians who performed breast cancer risk assessments, and who were more comfortable with breast density questions and follow-up decision making, were more likely to propose additional imaging. Male physicians were less likely to propose assessing breast cancer risk, and less likely to propose clinical and/or breast self-examinations. Divergence between practice and guidelines when it comes to supplemental breast cancer screening, coupled with density notification language that promotes additional screening in the absence of consistent evidence, remains concerning. Improved understanding of how density notification recipients and their physicians make decisions about supplemental screening is warranted to ensure that breast cancer risk is properly considered.

Patient Throughput Times for Supplemental Breast Cancer Screening Exams

Background: To optimize screening abbreviated breast MRI (ABMR) operations, patient throughput times of ABMR were compared to breast ultrasound (US) and full protocol breast MRI (FPMR).Methods: Patient throughput times (mean ± standard error) and its subcomponents were analyzed for 95 ABMRs, 90 breast US exams, and 50 FPMRs. Total patient throughput was measured from registration time to the time of the last acquired image. Actual exam time was time difference between the first and last acquired images and pre-examination time was the calculated difference between throughput and actual exam times. Results: ABMR total patient throughput time was shorter than FPMR (55.7 ± 1.7 vs. 63.1 ± 2.0 min; difference, 7.4 min, 13%; p<0.001), but longer than breast US (39.1 ± 1.3 min; difference, 16.6 min, 30%; p<0.001). ABMR had shorter actual scan times than FPMR (13.4 ± 0.14 vs. 18.6 ± 0.25 min; p<0.001), but longer than US (9.6 ± 0.46 minutes; p<0.001). There was no difference in the pre-examination times between ABMR and FPMR (42.3 ± 1.7 vs. 44.6 ± 1.9 min; p = 0.357); pre-examination times were longer for both MR exam types compared to US (29.5 ± 1.3 minutes; p<0.001). Conclusion: ABMR patient throughput times are faster than FPMR, but these gains are limited as they have no impact on pre-examination activities which comprise the lengthiest components of the patient flow process. US patient flow currently remains faster than ABMR; however, comparable ABMR times could be achieved by further omitting certain sequences and optimizing pre-examination processes.

Predictive Value of PI-RADS Is Low and Variable. Or Is It? Lessons We Can Learn from BI-RADS

HomeRadiology: Imaging CancerVol. 2, No. 6 PreviousNext Research HighlightsFree AccessPredictive Value of PI-RADS Is Low and Variable. Or Is It? Lessons We Can Learn from BI-RADSMateus TaveiraMateus TaveiraMateus TaveiraPublished Online:Nov 27 2020https://doi.org/10.1148/rycan.2020209033MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked InEmail Take-Away Points■ Major Focus: The Prostate Imaging Reporting and Data System (PI-RADS) classification system for prostate MRI established a standardized five-point scale for likelihood of clinically significant prostate cancer from 1 (very low) to 5 (very high). The true positive predictive value (PPV) of each PI-RADS category remains poorly validated.■ Key Result: In a retrospective cross-sectional study across 26 centers, PPV of PI-RADS ≥3 lesions (ie, intermediate to very high chance of malignancy) was 35% with large variability among centers and within a single center.■ Impact: PPV of PI-RADS classification system varies widely, but some centers have commendable precision and accuracy. Identifying factors contributing to high performance in some centers will improve global reproducibility and accreditation for prostate MRI.Because of adverse consequences of overdiagnosis and overtreatment of prostate cancer, imaging societies have developed standardized classification and reporting systems for prostate MRI (PI-RADS). PI-RADS version 2.1, updated in 2019, has been implemented worldwide. Despite single-center published data supporting the value of PI-RADS, concerns persist regarding its cross-center comparability and, more importantly, if the published performances could be replicated in community centers where most cancer screening occurs.Westphalen et al concluded that the PPV of PI-RADS was low and varied widely across centers. A historical comparison with BI-RADS, a much more mature reporting system for breast cancer screening, offers hope that the PPV of PI-RADS, even in the less accurate centers, is not that bad. Twenty-three years after initial publication of BI-RADS, an analysis by Salim et al showed that even among 24 high-volume readers, the PPV of an abnormal screening examination (BI-RADS categories 0, 4 or 5) was 8% and ranged from 4% to 14%. High-volume readers all had similar specificity (93%–99%), and variations in PPV arose from differences in reader sensitivity (53%–86%).The historical evolution of BI-RADS and breast cancer screening provides a path to make PI-RADS more accurate in a much shorter time frame. First, systematic biopsy of the prostate allows more opportunities to evaluate MRI findings against pathology samples, as compared with breast biopsy that only samples the suspicious area. Second, unlike mammograms, multiparametric MRI offers not only morphologic but also functional information, and MRI technologies for prostate MRI continue to advance more rapidly than mammography. Finally, the prostate cancer community can learn from BI-RADS strategies for audits and accreditation to kickstart the PI-RADS qualification process. Radiologists are not the only professionals involved in prostate cancer screening, but their involvement in the field through research, education, and quality control will be paramount for improving the lives of these patients while minimizing the risks of overdiagnosis and overtreatment.Highlighted ArticlesWestphalen AC, McCulloch CE, Anaokar JM, et al. Variability of the positive predictive value of PI-RADS for prostate MRI across 26 centers: experience of the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel. Radiology 2020;296(1):76–84. doi:10.1148/radiol.2020190646Salim M, Dembrower K, Eklund M, Lindholm P, Strand F. Range of radiologist performance in a population-based screening cohort of 1 million digital mammography examinations Radiology 2020;297(1):33–39. doi:10.1148/radiol.2020192212Highlighted ArticlesWestphalen AC, McCulloch CE, Anaokar JM et al. Variability of the positive predictive value of PI-RADS for prostate MRI across 26 centers: experience of the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel. Radiology 2020;296(1):76–84. doi:10.1148/radiol.2020190646 Link, Google ScholarSalim M, Dembrower K, Eklund M, Lindholm P, Strand F. Range of radiologist performance in a population-based screening cohort of 1 million digital mammography examinations Radiology 2020;297(1):33–39. doi:10.1148/radiol.2020192212 Link, Google ScholarArticle HistoryPublished online: Nov 27 2020 FiguresReferencesRelatedDetailsRecommended Articles Influence of Risk Category and Screening Round on the Performance of an MR Imaging and Mammography Screening Program in Carriers of the BRCA Mutation and Other Women at Increased RiskRadiology2017Volume: 286Issue: 2pp. 443-451ACR BI-RADS Assessment Category 4 Subdivisions in Diagnostic Mammography: Utilization and Outcomes in the National Mammography DatabaseRadiology2018Volume: 287Issue: 2pp. 416-422Additional Breast Cancer Detection at Digital Screening Mammography through Quality Assurance Sessions between Technologists and RadiologistsRadiology2020Volume: 294Issue: 3pp. 509-517Multicenter Evaluation of Breast Cancer Screening with Digital Breast Tomosynthesis in Combination with Synthetic versus Digital MammographyRadiology2020Volume: 297Issue: 3pp. 545-553Closing the Chapter on Supplemental Breast Cancer Screening with USRadiology2021Volume: 298Issue: 3pp. 576-577See More RSNA Education Exhibits Non-Contrast-Enhanced Breast MR Screening for Women with Dense BreastsDigital Posters2019The First 60 Days of COVID-19: A Mandatory Rapid and Unusual Distillation of Clinical Acuity of Breast Disease and Management ImplicationsDigital Posters2020BIRADS Mammography: What Do Residents Need to Know?Digital Posters2017 RSNA Case Collection Invasive Lobular CarcinomaRSNA Case Collection2021Invasive ductal carcinoma as developing asymmetryRSNA Case Collection2021Anterior transition zone prostate adenocarcinomaRSNA Case Collection2020 Vol. 2, No. 6 Metrics Downloaded 92 times Altmetric Score

Trends in screening breast magnetic resonance imaging use among US women, 2006 to 2016.

Supplemental breast cancer screening with breast magnetic resonance imaging (MRI) is recommended for women at high risk of breast cancer. To the authors' knowledge, recent national trends in breast MRI use are unknown. The authors used claims data from a large national insurer to calculate screening breast MRI rates from 2006 to 2016 in a US cohort of 10 million women aged 20 to 64 years. Use was stratified by subgroups of women with a BRCA mutation, family history of breast cancer, and prior breast cancer history and stratified by age. Joinpoint regression evaluated annual changes in trends. The total sample included 37,447 screening breast MRI examinations in 25,617 women. Overall screening breast MRI rates were low and increased from 2.9 to 12.1 examinations per 10,000 women from 2006 to 2016. MRI use in women with a BRCA mutation increased by 21% on average annually from 210.8 per 10,000 women to 1562.0 per 10,000 women from 2006 to 2016. By 2016, women aged 50 to 64 years who had a BRCA mutation had the highest use of breast MRI (1669.6 MRI examinations per 10,000 women) compared with younger women (1198.4 MRI examinations per 10,000 women, 1519.1 MRI examinations per 10,000 women, and 1567.2 MRI examinations per 10,000 women, respectively, among women aged 20-29 years, 30-39 years, and 40-49 years). Women with a BRCA mutation comprised <1% of the current study population but received approximately 9% of screening breast MRI examinations. Breast MRI rates among women with a family history of breast cancer or prior breast cancer history initially increased from 2006 to 2008, but then stabilized or decreased. The increases in breast MRI use observed in the current study have indicated improvements in concordance with breast imaging guidelines. However, women with BRCA mutations remain underscreened, particularly younger women, thereby identifying a clear gap with which to enhance access.

Availability Versus Utilization of Supplemental Breast Cancer Screening Post Passage of Breast Density Legislation.

Objective: Despite the lack of evidence that supplemental screening in women with dense breasts reduces breast cancer mortality, 38 states have passed breast density legislation, with some including recommendations for supplemental screening. The objective of this study is to compare the availability versus use of supplemental breast cancer screening modalities and determine factors driving use of supplemental screening in rural versus urban settings. Methods: A 50-item mailed survey using the Tailored Design Method was sent to American College of Radiology mammography-accredited facilities in North Carolina in 2017. Respondents included 94 facilities (48 rural and 46 urban locations). Survey questions focused on breast cancer and supplemental screening services, breast density, risk factors/assessment, and facility demographics. Results: The survey response rate was 60.3% (94/156). Among the 94 respondents, 64.0% (n = 60) reported availability of any type of supplemental screening (digital breast tomosynthesis [DBT], ultrasound, or magnetic resonance imaging [MRI]). In facilities where supplemental screening modalities were available, the most commonly utilized supplemental screening modality was DBT (96.4%), compared with ultrasound (35.7%) and MRI (46.7%). Facilities reported using supplemental screening based on patient breast density (48.3%), referring physician recommendation (63.3%), reading radiologist recommendation (63.3%), breast cancer risk factors (48.3%), and patient request (40.0%). Urban facilities were more likely than rural facilities to base supplemental screening on breast cancer risk factors (62.5% vs. 32.1%; p-value = 0.019), referring physician (75.0% vs. 50.0%; p-value = 0.045), and reading radiologist (78.1% vs. 46.4%; p-value = 0.011). Conclusion: In our study, supplemental screening modalities were widely available, with facilities more likely to use DBT for supplemental screening compared to other modalities.

Understanding the response of mammography facilities to breast density notification.

State-specific breast density notification legislation requires that women undergoing mammography be informed about breast density, with variation among states. Because mammography facilities are among the main points of contact for women undergoing mammography, research is needed to understand how facilities communicate information on breast density, cancer risk, and supplemental screening to women. A cross-sectional, 50-item, mailed survey of 156 American College of Radiology-certified mammography facilities in North Carolina was conducted in 2017 via the Tailored Design Method. Breast density notification practices, supplemental screening services, and patient educational materials were compared by supplemental screening availability via t tests and chi-square tests. All responding facilities (n=94; 60.3% response rate) notified women of their breast density in the mammography results letter. Breast cancer risk assessments were performed by 36.2% of the facilities, with risk information communicated in the final radiology report for the referring provider to discuss with the woman (79.4%) or in the results letter (58.8%). Supplemental breast cancer screening was offered by 63.8% of the facilities, with use based on multiple factors, including recommendations from the referring physician (63.3%) or reading radiologist (63.3%), breast density (48.3%), other risk factors (48.3%), and patient request (40.0%). Although 75.0% of the facilities offered breast density educational materials, only 36.6% offered educational materials on supplemental screening. In a state with a breast density notification law, mammography facilities communicate breast density, cancer risk, and supplemental screening information to women through various approaches. When supplemental screening is offered, facilities use multiple decision-making criteria rather than breast density alone.

Breast Density of Mammography is Correlated with Reproductive Risk Factors Regardless of Menopausal Status: A Cross-Sectional Study of the Korean National Screening Program.

Objective:To clarify the limitations of mammography screening for women with dense breasts, we examined breast density and its effects on screening results. Patients and Methods:We performed a cross-sectional, observational study on women who underwent mammography. Data from the National Cancer Screening Program(NCSP) from 2009 to 2013 were used. The study population consisted of participants with high breast density. We used a logistic regression analysis to evaluate the relationships between breast density and reproductive factors and screening results according to menopause status. Results:High breast density was reported for 57.5% of all participants (3,417,319 participants). Screening results indicated breast density of <25%, 25-50%, 51-75%, and ≥76% for 16.4%, 26.3%, 37.8%, and 19.5%, respectively, of participants. According to the screening results, high breast density was correlated with high deferment and recall rates. Reproductive factors, especially parity, breastfeeding, and use of oral contraceptives, had consistent effects on screening results of premenopausal and postmenopausal women. Regardless of menopausal status, age, early onset of menarche (15 years or younger), fewer live births (≤1 birth), and previous benign breast disease were correlated with increased breast density. In postmenopausal women, early-onset menopause and longer-term hormone replacement therapy (≥2 years) also independently increased breast density.Conclusion:Breast density influenced screening results, which could increase the rate of recall. Breast density was also influenced by reproductive factors, with patterns similar to those of breast cancer risk, regardless of menopausal status. We need to identify high-risk women with high density who would probably benefit from supplemental breast cancer screening.

Trends of Supplemental Screening in Women With Dense Breasts

The objective of this study was to survey current trends in supplemental screening across various practice types and to understand factors that affect these practice patterns. In this institutional review board-exempt study, a 12-question survey was sent out to ACR lead interpreting physicians. The survey inquired about practice features and the utilization of supplemental screening. A total of 902 of 4,688 lead interpreting breast imaging physicians (19.2%) responded to our survey. Of those respondents, 617 respondents (68.4%) worked in practices that offered supplemental breast cancer screening. Screening ultrasound was the most commonly utilized supplemental screening modality (53%). There was variability in methods of referral for supplemental screening, with referral through the ordering provider (56%) being the most common. Academic practices, private practices with breast specialization, and practices in the Northeast were more likely to provide supplemental screening (P < .05). There were significant relationships between the presence of state density notification legislation, the number of breast imaging trained radiologists, and the volume of mammographic studies performed per day and the availability of supplemental screening (P < .05). The use of automated breast density assessment software and patient education brochures about density and supplemental screening also had significant relationships with the availability of supplemental screening (P < .05). The majority of practices surveyed are utilizing supplemental screening, but there is significant variability in the modalities used and the methods of referral. There are practice features that correlate with the availability of supplemental screening, and understanding these features provides further insight into current trends in supplemental screening utilization.

Effect of Mammographic Screening Modality on Breast Density Assessment: Digital Mammography versus Digital Breast Tomosynthesis.

Background Breast Imaging Reporting and Data System (BI-RADS) breast density categories assigned by interpreting radiologists often influence decisions surrounding supplemental breast cancer screening and risk assessment. The landscape of mammographic screening continuously evolves, and different mammographic screening modalities may result in different perception of density, reflected in different assignment of BI-RADS density categories. Purpose To investigate the effect of screening mammography modality on BI-RADS breast density assessments. Materials and Methods Data were retrospectively analyzed from 24 736 individual women (42.3% [10 455 of 24 736] white women, 57.7% [14 281 of 24 736] black women; mean age, 56.3 years; age range, 40.0-74.9 years) who underwent from one to seven mammographic screening examinations from September 2010 through February 2017 (60 766 examinations). Three screening modalities were used: digital mammography alone (8935 examinations); digital mammography with digital breast tomosynthesis (DBT; 30 779 examinations); and synthetic mammography with DBT (21 052 examinations). Random-effects logistic regression analysis was performed to estimate the likelihood of assignment to high versus low BI-RADS density category according to each modality, adjusted for ethnicity, age, body mass index (BMI), and radiologist. The interactions of modality with ethnicity and BMI on density categorization were also tested with the model. Results Women screened with DBT versus digital mammography alone had lower likelihood regarding categorization of high density breasts (digital mammography and DBT vs digital mammography: odds ratio, 0.69 [95% confidence interval: 0.61, 0.80], P < .001; synthetic mammography and DBT vs digital mammography: odds ratio, 0.43 [95% confidence interval: 0.37, 0.50], P < .001). Lower likelihood of high density was also observed at synthetic mammography and DBT compared with digital mammography and DBT (odds ratio, 0.62; 95% confidence interval: 0.56, 0.69; P < .001). There were interactions of modality with ethnicity (P = .007) and BMI (P = .003) on breast density assessment, with greater differences in density categorization according to modality observed for black women than for white women and groups with higher BMI. Conclusion Breast density categorization may vary by screening mammographic modality, and this effect appears to vary by ethnicity and body mass index. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Philpotts in this issue.

Between-Race Differences in Supplemental Breast Cancer Screening Before and After Breast Density Notification Law

Guidelines recommend supplemental breast cancer screening for women at increased breast cancer risk; however, the passage of breast density notification laws may lead to supplemental screening that is incongruent with women’s risk. We examined supplemental screening (ie, MRI, ultrasound, or tomosynthesis within 6 months of screening mammogram) among a sample of 2,764 African American (AA) and 691 European American (EA) women with negative or benign screening mammograms for whom we had data from both before and after implementation of breast density notification laws in the state of Michigan. Results indicated a 5-fold increase (from 0.14% to 0.7% of women) in supplemental screening among screen-negative women after passage of the law, driven in large part by an increase in supplemental screening among AA women. Breast density was more predictive of supplemental screening and had a marginally greater explanatory role in between-race differences in supplemental screening after passage of the law. Subgroup analyses (n = 250) indicated that whereas 5-year breast cancer risk was positively associated with supplemental screening before the law and negatively associated after the law for EA women, 5-year risk was not associated with supplemental screening either before or after passage of the law for AA women. Our findings suggest that whereas passage of the breast density notification laws may have motivated supplemental screening among AA women in particular, it lessened the consideration of breast cancer risk in supplemental screening decision making.

The Role of Ultrasound in Breast Cancer Screening: The Case for and Against Ultrasound

Mammography is the gold standard for breast cancer screening. However, with increasing awareness among patients and health care providers of mammography limitations especially in dense breasts, supplemental screening for breast cancer with ultrasound and magnetic resonance imaging has been expanding. The roles of both in screening need to be re-examined. This article reviews the efficacy, utility, and feasibility of ultrasound as a screening tool for the early detection of occult breast cancer.

Breast Density Awareness and Knowledge, and Intentions for Breast Cancer Screening in a Diverse Sample of Women Age Eligible for Mammography.

The objectives of this study were to assess breast density knowledge and breast density awareness, and to identify information associated with intention to complete routine and supplemental screening for breast cancer in a diverse sample of women age eligible for mammography. We quantitatively (self-report) assessed breast density awareness and knowledge (N=264) in black (47.7%), Latina (35.2%), and white (17%) women recruited online and in the community. Most participants reported having heard about breast density (69.2%); less than one third knew their own breast density status (30.4%). Knowing their own breast density, believing that women should be notified of their breast density in their mammogram report, and feeling informed if being provided this information are associated with likelihood of completing mammogram. Intending mammogram completion and knowledge regarding the impact of breast density on mammogram accuracy are associated with likelihood of completing supplemental ultrasound tests of the breast. These findings help inform practitioners and policy makers about information and communication factors that influence breast cancer screening concerns and decisions. Knowing this information should prepare practitioners to better identify women who may have not been exposed to breast density messages.

The need for supplemental breast cancer screening modalities: a perspective of population-based breast cancer screening programs in Japan.

This article discusses possible supplemental breast cancer screening modalities for younger women with dense breasts from a perspective of population-based breast cancer screening program in Japan. Supplemental breast cancer screening modalities have been proposed to increase the sensitivity and detection rates of early stage breast cancer in women with dense breasts; however, there are no global guidelines that recommend the use of supplemental breast cancer screening modalities in such women. Also, no criterion standard exists for breast density assessment. Based on the current situation of breast imaging in Japan, the possible supplemental breast cancer screening modalities are ultrasonography, digital breast tomosynthesis, and breast magnetic resonance imaging. An appropriate population-based breast cancer screening program based on the balance between cost and benefit should be a high priority. Further research based on evidence-based medicine is encouraged. It is very important that the ethnicity, workforce, workflow, and resources for breast cancer screening in each country should be considered when considering supplemental breast cancer screening modalities for women with dense breasts.

Supplemental Breast Cancer Screening With Molecular Breast Imaging for Women With Dense Breast Tissue.

Molecular breast imaging was implemented in routine clinical practice at a large community-based breast imaging center. The aim of this study was to retrospectively assess the clinical performance of molecular breast imaging as a supplementary screening tool for women with dense breast tissue. Women with dense breasts and negative mammography results who subsequently underwent screening with 300 MBq (8 mCi) (99m)Tc-sestamibi molecular breast imaging were retrospectively analyzed. Outcome measures included cancer detection rate, recall rate, biopsy rate, and positive predictive values (PPVs). Molecular breast imaging screening of 1696 women in this study resulted in the detection of 13 mammographically occult malignancies, of which 11 were invasive, one was node positive, and one had unknown node positivity. The lesion size ranged from 0.6 to 2.4 cm, with a mean of 1.1 cm. The incremental cancer detection rate was 7.7‰ (95% CI, 4.5-13.1‰), the recall rate was 8.4% (95% CI, 7.2-9.8%), and the biopsy rate was 3.7% (95% CI, 2.9%-4.7%). The PPV for recall (PPV 1) was 9.1% (95% CI, 5.4-15.0%), and the PPV for biopsy (PPV 3) was 19.4% (95% CI, 11.4-30.9%). When incorporated into a community-based clinical practice environment, molecular breast imaging yielded a high incremental cancer detection rate of 7.7‰ at an acceptable radiation dose. These results show the utility of molecular breast imaging as a supplementary screening tool to mammography for women with dense breasts.

Supplemental Screening for Breast Cancer in Women With Dense Breasts: A Systematic Review for the U.S. Preventive Services Task Force.

Screening mammography has lower sensitivity and specificity in women with dense breasts, who experience higher breast cancer risk. To perform a systematic review of reproducibility of Breast Imaging Reporting and Data System (BI-RADS) density categorization and test performance and clinical outcomes of supplemental screening with breast ultrasonography, magnetic resonance imaging (MRI), and digital breast tomosynthesis (DBT) in women with dense breasts and negative mammography results. MEDLINE, PubMed, EMBASE, and Cochrane database from January 2000 to July 2015. Studies reporting BI-RADS density reproducibility or supplemental screening results for women with dense breasts. Quality assessment and abstraction of 24 studies from 7 countries; 6 studies were good-quality. Three good-quality studies reported reproducibility of BI-RADS density; 13% to 19% of women were recategorized between "dense" and "nondense" at subsequent screening. Two good-quality studies reported that sensitivity of ultrasonography for women with negative mammography results ranged from 80% to 83%; specificity, from 86% to 94%; and positive predictive value (PPV), from 3% to 8%. The sensitivity of MRI ranged from 75% to 100%; specificity, from 78% to 94%; and PPV, from 3% to 33% (3 studies). Rates of additional cancer detection with ultrasonography were 4.4 per 1000 examinations (89% to 93% invasive); recall rates were 14%. Use of MRI detected 3.5 to 28.6 additional cancer cases per 1000 examinations (34% to 86% invasive); recall rates were 12% to 24%. Rates of cancer detection with DBT increased by 1.4 to 2.5 per 1000 examinations compared with mammography alone (3 studies). Recall rates ranged from 7% to 11%, compared with 7% to 17% with mammography alone. No studies examined breast cancer outcomes. Good-quality evidence was sparse. Studies were small and CIs were wide. Definitions of recall were absent or inconsistent. Density ratings may be recategorized on serial screening mammography. Supplemental screening of women with dense breasts finds additional breast cancer but increases false-positive results. Use of DBT may reduce recall rates. Effects of supplemental screening on breast cancer outcomes remain unclear. Agency for Healthcare Research and Quality.

Recent Findings May Inform Breast Density Notification Laws

Arecent study that questions the effectivenessof supplemental breast cancer screening for women with densebreasts couldbeona collision course with state laws mandating that women be notified if a mammogram shows they have high breast density. Experts say that about 40% to 50%of womenhavedensebreast tissue,whichhas been associated with higher breast cancer risk. Adding ultrasonography to mammography often is suggested because limited data indicate that it can strengthen breast cancer detection rates. Even so, uncertainty has surrounded whether the additional screening improves long-term outcomes and whether it’s cost-effective. But data published late last year show that supplemental ultrasonography produces only small health benefits while it substantially increases costs (Sprague BL et al. Ann Intern Med. doi:10.7326/M14-0692 [published online December 9, 2014]). Breast tissue is considered “dense” if it has excess fibrous or glandular tissue, according to the American College of Radiology. Some estimates have suggested that mammographic density accounts for 16% of all breast cancers (Assi V et al. Nat Rev Clin Oncol. 2012;9[1]:33-40). Consequently, these types of data helped build momentum for laws that require notification of women with dense breasts, largely led by a grassroots movement called “Are You Dense?” Women Need Information Nancy M. Cappello, PhD, has been a key force behind the state-by-state legislation for breast density notification. She has written about her personal experience, which began when her own mammogram was reported as being normal (Cappello NM. J Am Coll Radiol. 2013;10[12]:903908). Only 2 months later, however, she was diagnosed with stage IIIC breast cancer. As she wrote in the article, “My radiologist knew that I had dense breasts. My doctor knew that I had dense breasts. The only person who did not know was me: the woman with the dense breasts.” In fact, according to data published on the “Are You Dense?” website, 95% of women do not know their breast density (http:// www.areyoudense.org/). Fewer than 1 in 10 women learn about their dense breast tissue from their own physicians. In2009,Connecticutwas the first state to implement a breast density notification law requiring women to be notified after a mammogram showed they had high breast density. Since then, 19 other states have joined the movement by enacting laws of their own, with Ohio joining the roll in December 2014. Nearly a dozen additional statesareconsideringsimilar legislation,with only minor differences among the laws of participating states. Federal legislation also is on the drawing board in Congress—the so-called Breast Density and Mammography Reporting Act of 2015. The act would require that a mammography report summary be delivered to patients indicating their breast density according to standardized density measurements used throughout the United States.

Training and standards for performance, interpretation, and structured reporting for supplemental breast cancer screening.

OBJECTIVE. To compensate for the reduction of mammography's sensitivity in women with dense breasts, supplemental screening can increase the cancer detection rate. The modalities suggested are MRI, which is the most sensitive and is indicated for women with the highest risk of breast cancer, and ultrasound, which is suggested for dense-breasted average-risk women. CONCLUSION. For decades, ultrasound has been a focused examination. Extending a handheld ultrasound examination to depict the entire breast requires formal didactic training and hands-on scanning to learn suitable, efficient methods. Automated options also require intensive training in performance and interpretation.