Women Undergoing Screening Mammography Research Articles

Estimation of Abnormal Findings in Screening Mammography: A Crosssectional Descriptive Study

Introduction: Breast cancer is the second leading cause of death in women of Nepal. Breast cancer awareness and clinical breast examination are the key steps for early detection of breast cancer in countries with limited resources like Nepal. Meanwhile, screening mammography can be used as a major tool to detect breast cancer at an early stage before development of signs such as lump. Screening mammography is very effective in detection of breast cancer. The aim of this study was to estimate the abnormal findings in screening mammography. Methods: Quantitative, cross-sectional, descriptive study was performed in the Department of Radiology and Imaging of Civil Service Hospital. Data was collected over a period of 6 months (April to September 2018) of female patients who visited for screening mammography were included in this study. Results: Out of total 90 female patients, in screening mammography, 42.22% were benign lesions like macro calcifications and cysts, while 57.78% were normal findings. There was no evidence of breast malignancy in the study group. Among the age group of 35-44 years 15.38 % had abnormal findings. Women undergoing screening mammography were mostly in the age group of 45-54 where 53.47 % of 43 women had abnormalities. Similarly only 10 out of 18 and 1 out of 3 had abnormalities in the age group of 55-64 and 65 and above respectively. Conclusion: The study concluded that the abnormal findings in females who visited for screening mammography were benign lesions i.e. calcifications and cysts

Abstract PD16-02: Factors Associated with Receipt of Digital Breast Tomosynthesis Among Racially/Ethnically Diverse Women Undergoing Screening Mammography

Abstract Introduction: Digital breast tomosynthesis (DBT) is increasingly utilized in breast cancer screening, including among women at high risk for breast cancer. While there is a lack of rigorous data from randomized controlled trials demonstrating superior efficacy compared to two-dimensional (2D) digital mammography, observational studies suggest that DBT might have lower rates of false-positive results and increased detection of invasive cancer than 2D mammography. However, uptake of DBT might be lower among racial/ethnic minorities, which could contribute to breast cancer disparities. We evaluated whether sociodemographic and breast cancer risk factors were associated with receipt of DBT vs. 2D mammography among a racially/ethnically diverse population of women undergoing screening mammography. Methods: We conducted a respective cohort study among women, age 40-74 years, who underwent screening mammography at Columbia University Irving Medical Center (CUIMC) in New York, NY, from February 2020 to January 2022. We extracted data from the electronic health record (EHR) on age, race/ethnicity, first-degree family history of breast cancer (yes/no), prior breast biopsies (yes/no), and mammographic breast density (high vs. low), and calculated individual 5-year risks of invasive breast cancer according to the Breast Cancer Surveillance Consortium (BCSC) model. High risk was defined as a 5-year invasive breast cancer risk 1.67%. Our primary outcome was receipt of at least one DBT screening examination from 2020-2022 (yes/no). We conducted multivariable logistic regression analyses to assess the association between demographic/clinical factors and receipt of DBT. Results: Among 5617 evaluable women, mean age was 55.4 years (SD, 9.5 years) and 56% identified as non-Hispanic White, 10% as non-Hispanic Black, 17% as Hispanic, 8% as Asian, and 9% other/unknown. Over 60% of women had high breast density, and 34% met high-risk criteria. Seventy percent of women had at least one DBT from 2020-2022. In multivariable analyses (Table 1), women with high vs. low breast density were 2.5 times more likely to receive DBT (odds ratio [OR]=2.51, 95% confidence interval [CI]=2.19-2.88), while first-degree family history of breast cancer, prior breast biopsy, and age were inversely associated with DBT. Racial/ethnic minorities were less than half as likely to undergo DBT compared to non-Hispanic Whites; for example, Hispanic women were over 85% less likely to receive DBT (OR=0.14, 95% CI=0.11-0.16). Overall, there was no association between breast cancer risk status (high vs. low/average) and receipt of DBT (OR=1.00, 95% CI 0.92-1.08). Conclusion: We observed that the majority of women undergoing screening mammography at CUIMC from 2020-2022 received DBT for breast cancer screening. However, racial/ethnic minorities, including non-Hispanic Blacks and Hispanics, were significantly less likely than non-Hispanic Whites to have received DBT. Breast cancer risk according the BCSC model was also not associated with receipt of DBT. Future studies should determine which subsets of women are more likely to benefit from DBT. Citation Format: Julia E. McGuinness, Gargi Patel, Jacquelyn N. Amenta, Rita Kukafka, Katherine D. Crew. Factors Associated with Receipt of Digital Breast Tomosynthesis Among Racially/Ethnically Diverse Women Undergoing Screening Mammography [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD16-02.

Abstract P4-03-23: Comparison of Breast Cancer vs Cardiovascular Disease Risk and Uptake of Chemoprevention vs Statins in a Cohort of Predominantly Hispanic Women Undergoing Screening Mammography

Abstract Background: Atherosclerotic cardiovascular disease (ASCVD) and breast cancer are two of the most diagnosed chronic diseases among women in the U.S. Although prevention of ASCVD with statins is widely practiced, breast cancer chemoprevention with selective estrogen receptor modulators (SERMs) or aromatase inhibitors (AIs) is underutilized in the primary care setting, despite significant evidence in randomized controlled trials demonstrating its clinical benefits. We compared the risk of ASCVD and breast cancer among predominantly Hispanic women undergoing screening mammography, as well as uptake of statins and SERMs/AIs for ASCVD and breast cancer risk reduction, respectively, among high-risk women. Methods: We conducted a retrospective cohort study among 1,655 English or Spanish-speaking women, age 40-79 years, with no prior history of breast cancer, who underwent screening mammography from 2014 to 2016 at Columbia University Irving Medical Center in New York City. Participants completed a survey collecting data on sociodemographic and breast cancer risk factors and had available data in the electronic health record (EHR) for calculating ASCVD risk, including systolic blood pressure, total and HDL cholesterol, history of diabetes, treatment for hypertension, and current smoking status. The main outcomes included 5-year and lifetime invasive breast cancer risk according to the Gail model, and 10-year and lifetime ASCVD risk score according to the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) ASCVD risk calculator. High-risk was defined as a 5-year invasive breast cancer risk 1.67% and 10-year ASCVD risk 7.5%. Secondary outcomes included uptake of chemoprevention with SERMs or AIs and statins among women at high-risk for breast cancer and ASCVD, respectively, based upon medication lists in the EHR. We compared mean lifetime risk of breast cancer vs ASCVD for the entire cohort using a paired t-test, and the proportion of high-risk women taking statins vs chemoprevention using McNemar’s test. Results: Among 1,655 evaluable women, mean age was 58 years (SD=10.1 years), with 76% Hispanic, 6% non-Hispanic White, 3% non-Hispanic Black, 2% Asian, and 13% other. About half (48%) of women met high-risk criteria for ASCVD compared to 15% who met high-risk criteria for breast cancer. Among all women, mean lifetime ASCVD risk was higher than mean lifetime breast cancer risk (10.71% vs. 5.46%, p< 0.001). Among women at high risk for ASCVD or breast cancer, respectively, statin uptake was higher compared to SERM/AI uptake for breast cancer chemoprevention (84% vs. 7%, p< 0.001). Overall, fewer Hispanic compared to non-Hispanic women met high-risk criteria for ASCVD (47% vs. 51%, respectively) and breast cancer (9% vs. 34%, respectively). Conclusions: In a population of predominantly Hispanic women undergoing screening mammography, we found that more women met high-risk criteria for ASCVD compared to breast cancer. Among women at high risk for ASCVD, statin uptake was about 12-fold higher compared to uptake of breast cancer chemoprevention among women at high risk for breast cancer. Given significant underutilization of breast cancer chemoprevention, placing this in the context of prevention of other chronic diseases, such as statins for ASCVD, may enhance uptake of SERMs or AIs in the primary care setting. Citation Format: Luisa Nilan, Mary M. McDermid, Jacquelyn N. Amenta, Julia E. McGuinness, Katherine D. Crew, Rita Kukafka. Comparison of Breast Cancer vs Cardiovascular Disease Risk and Uptake of Chemoprevention vs Statins in a Cohort of Predominantly Hispanic Women Undergoing Screening Mammography [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-03-23.

Breast Arterial Calcification in Screening Mammograms and its Correlation with Carotid Intima Media Thickness: A Cross-sectional Study

Introduction: Atherosclerosis is a leading cause of cardiovascular mortality worldwide. According to American Cancer Society (ACS) guidelines, screening mammography is optional for all women above the age of 40 years to detect breast cancer early. Incidentally, Breast Arterial Calcification (BAC) can be observed in mammograms. Women with BAC and additional risk factors like diabetes or hypertension may be referred for cardiovascular risk assessment in the future if there is a significant correlation between Carotid Intima Media Thickness (CIMT) and BAC. Aim: To assess BAC among women undergoing screening mammography and determine the correlation between BAC and CIMT. Materials and Methods: A cross-sectional study was conducted on 152 women who underwent screening mammography in the Department of Radiodiagnosis, Amala Institute of Medical Sciences, Thrissur, Kerala, India from May 2021 to October 2022. The presence and grading of BAC were determined using the Seimens Mammomat 1000 mammography unit, which captured two standard views: the Mediolateral Oblique (MLO) and Craniocaudal (CC) views. CIMT was measured using B-mode ultrasonography with an 8-13 MHz linear transducer, taking measurements from two contiguous sites at 1 cm intervals and calculating the average. Statistical significance was assessed at a 5% level, and the association was determined using Spearman’s rho correlation. Results: The mean age of the study population was 55.7±11.05 years. Among them, only 37 (24.3%) showed the presence of calcification in the breast arteries. The mean CIMT was 0.92±0.25 mm in the BAC (+) group and 0.72±0.24 mm in the BAC (-) group (p-value=0.001). Conclusion: The authors developed a BAC grading method after studying various previous studies and the present study found a significant positive correlation between the presence of BAC and CIMT.

Diagnostic Accuracy of Opportunistic Breast Cancer Screening Based on Mammography in Iran

Background: Although breast cancer is the most prevalent type of cancer among Iranian women, its screening is opportunistic in Iran. The available guidelines for breast cancer screening are based on mammography. A screening modality should have adequate diagnostic accuracy and be widely available at reasonable cost. Although mammography is highly accessible in Iran, its accuracy has not been investigated. Objectives: This study aimed to evaluate the accuracy of mammography in opportunistic screening regarding the current rate of patient attendance. Patients and Methods: A total of 491 women undergoing screening mammography were followed-up based on their medical records. They were divided into positive and negative screening groups, based on the breast imaging-reporting and data system (BI-RADS) categories and approaches. To evaluate the disease status of positive cases, pathology reports were investigated, and negative cases were followed-up for stability over time. Results: In the study sample, sensitivity was estimated at 73.08% (95% CI: 55.21 - 88.93), specificity was estimated at 94.41% (95% CI: 91.91 - 96.32), and accuracy was 93.28% (95% CI: 90.69 - 95.33). These test accuracy indices were not significantly different between the groups regarding age, family history, breast density, and history of breast interventions. Conclusion: The test’s sensitivity or ability to detect a disease was relatively low in opportunistic screening; it was found to be similar to the results of studies of first time implementation of screeninng. In both settings, a test needs to diagnose both incident and prevalent cases. The overall accuracy of mammography was acceptable, even in opportunistic screening.

Association between fat-infiltrated axillary lymph nodes on screening mammography and cardiometabolic disease.

Ectopic fat deposition within and around organs is a stronger predictor of cardiometabolic disease status than body mass index (BMI). Fat deposition within the lymphatic system is poorly understood. This study examined the association between the prevalence of cardiometabolic disease and ectopic fat deposition within axillary lymph nodes (LNs) visualized on screening mammograms. A cross-sectional study was conducted on 834 women presenting for full-field digital screening mammography. The status of fat-infiltrated LNs was assessed based on the size and morphology of axillary LNs from screening mammograms. The prevalence of cardiometabolic disease was retrieved from the electronic medical records, including type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, high blood glucose, cardiovascular disease, stroke, and non-alcoholic fatty liver disease. Fat-infiltrated axillary LNs were associated with a high prevalence of T2DM among all women (adjusted odds ratio: 3.92, 95% CI: [2.40, 6.60], p-value < 0.001) and in subgroups of women with and without obesity. Utilizing the status of fatty LNs improved the classification of T2DM status in addition to age and BMI (1.4% improvement in the area under the receiver operating characteristic curve). Fat-infiltrated axillary LNs visualized on screening mammograms were associated with the prevalence of T2DM. If further validated, fat-infiltrated axillary LNs may represent a novel imaging biomarker of T2DM in women undergoing screening mammography.

Microcalcification Detection in Mammograms Using Deep Learning

Background: Mammography is the most reliable and popular method in the clinical diagnosis of breast cancer. Calcifications are subtle lesions in mammograms that can be cancerous and difficult to detect for radiologists. Computer-aided detection (CAD) can help radiologists identify malignant lesions. Objectives: This study aimed to propose a deep learning based CAD system for detecting calcifications in mammograms. Patients and Methods: A total of 815 in-house mammograms were collected from 204 women undergoing screening mammography. Calcifications in the mammograms were annotated by specialists. Each mammogram was divided into patches of fixed size, and then, patches containing calcifications were extracted, along with the same number of normal patches. A ResNet-50 Convolutional Neural Network (CNN) was trained for classification of patches into normal and calcification groups using training data and then the performance of the trained CNN was tested with new test data. Results: The proposed patch learning approach (PLA) showed a classification accuracy of 96.7% in the binary classification of patches. Therefore, it could detect calcification regions in a given mammogram. The PLA achieved sensitivity and specificity of 96.7% and 96.7%, respectively, with an area under the curve of 98.8%. Conclusion: The present results highlighted the efficacy of the proposed PLA, especially for limited training data. Direct comparison with previous studies is not possible due to differences in datasets. Nevertheless, the PLA accuracy in detecting calcifications was higher than that of deep learning based CAD systems in previous studies. The effective performance of PLA may be attributed to the manual removal of uninformative patches, as they were not used in the training set.

Abstract P2-10-03: Improving breast cancer risk prediction using a convolutional neural network-based mammographic evaluation in combination with clinical risk factors

Abstract Background: Accurate assessment of a woman’s individualized breast cancer risk is necessary to inform shared decision-making regarding screening and risk-reducing strategies. Recently, deep learning techniques, including convolutional neural networks (CNN), have shown better predictive potential for breast cancer risk compared to mammographic density (MD). We evaluated whether combining clinical factors in the Breast Cancer Surveillance Consortium (BCSC) model, including MD, with a novel CNN-based mammographic evaluation more accurately predicts breast cancer risk than the BCSC model alone in a cohort of racially/ethnically diverse women. Methods: We conducted a retrospective cohort study of 23,552 women, age 35-74 years, who underwent screening mammography from 2014 to 2018 at Columbia University Irving Medical Center in New York City. We extracted data from the electronic health record (EHR) on breast cancer risk factors (age, race/ethnicity, prior benign breast biopsy, first degree family history of breast cancer, and MD). From this cohort, we identified 206 women who developed breast cancer by linkage to the tumor registry. We calculated 5-year invasive breast cancer risk using the BCSC model. We applied CNN-based breast cancer risk model to full-field craniocaudal mammographic views of both breasts, with an output of a risk score (range, 0-1). We used logistic regression models with breast cancer status as the outcome and predictors including clinical factors only (BCSC model) or combined with CNN risk score (hybrid model). We compared the prediction performance of these models via area under the receiver operating characteristics curves (AUCs) based on the DeLong test. We also calculated each model’s AUC for subgroups of age and race/ethnicity. Results: Among 23,552 evaluable women, mean age was 55.9 years (standard deviation [SD], 9.5) with 27% non-Hispanic White, 9% non-Hispanic Black, 36% Hispanic, 5% Asian, and 23% Other/Unknown race/ethnicity. Four percent had a first-degree family history of breast cancer, 10% had a prior benign breast biopsy, 45% had heterogeneously or extremely dense breasts on mammography, and 22% met high-risk criteria based upon a 5-year invasive breast cancer risk 1.67% according to the BCSC model. Mean CNN risk score was higher among breast cancer cases compared to unaffected controls (0.477 vs. 0.466, p=0.077). We found that the hybrid model outperformed the BCSC model (AUC of 0.676 vs. 0.640, respectively; p=0.003). In subgroup analyses, the hybrid model more accurately predicted breast cancer risk compared to the BCSC model among women age&amp;lt;50 (AUC of 0.713 vs. 0.645, respectively; p=0.078) and age&amp;gt;=50 (AUC of 0.663 vs. 0.625, respectively; p=0.026); non-Hispanic Black women (AUC of 0.794 vs. 0.663, respectively; p=0.028) and Hispanic women (AUC of 0.666 vs. 0.621, respectively; p=0.060). Conclusion: Among women undergoing screening mammography, a hybrid model incorporating a CNN-based mammography evaluation with clinical factors from the BCSC model more accurately predicted breast cancer risk relative to the BCSC model alone, particularly among racial and ethnic minorities. Combined with clinical risk factors, our CNN model may be used to efficiently predict breast cancer risk and inform risk-stratified breast cancer screening and prevention strategies. Comparing prediction performance for breast cancer risk of the BCSC model vs. hybrid modelBCSC ModelHybrid ModelP-value*AUC95% CIAUC95% CIAll patients0.6400.602-0.6830.6760.640-0.7110.003Age (years)&amp;lt;500.6450.562-0.7280.7130.648-0.7780.078&amp;gt;=500.6250.579-0.6710.6630.623-0.7030.026Race/ethnicityNon-Hispanic White0.6880.623-0.7540.7040.643-0.7660.230Non-Hispanic Black0.6630.539-0.7880.7940.704-0.8830.028Hispanic0.6210.560-0.6860.6660.597-0.7330.060Asian0.6160.440-0.7910.6510.461-0.8410.694 Citation Format: Alissa Michel, Vicky Ro, Julia E McGuinness, Simukayi Mutasa, Richard Ha, Katherine D Crew. Improving breast cancer risk prediction using a convolutional neural network-based mammographic evaluation in combination with clinical risk factors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-10-03.

Validation of Breast Cancer Risk Models by Race/Ethnicity, Family History and Molecular Subtypes.

(1) Background: The purpose of this study is to compare the performance of four breast cancer risk prediction models by race, molecular subtype, family history of breast cancer, age, and BMI. (2) Methods: Using a cohort of women aged 40-84 without prior history of breast cancer who underwent screening mammography from 2006 to 2015, we generated breast cancer risk estimates using the Breast Cancer Risk Assessment tool (BCRAT), BRCAPRO, Breast Cancer Surveillance Consortium (BCSC) and combined BRCAPRO+BCRAT models. Model calibration and discrimination were compared using observed-to-expected ratios (O/E) and the area under the receiver operator curve (AUC) among patients with at least five years of follow-up. (3) Results: We observed comparable discrimination and calibration across models. There was no significant difference in model performance between Black and White women. Model discrimination was poorer for HER2+ and triple-negative subtypes compared with ER/PR+HER2-. The BRCAPRO+BCRAT model displayed improved calibration and discrimination compared to BRCAPRO among women with a family history of breast cancer. Across models, discriminatory accuracy was greater among obese than non-obese women. When defining high risk as a 5-year risk of 1.67% or greater, models demonstrated discordance in 2.9% to 19.7% of patients. (4) Conclusions: Our results can inform the implementation of risk assessment and risk-based screening among women undergoing screening mammography.

Breast biopsy patterns and findings among older women undergoing screening mammography: The role of age and comorbidity

IntroductionLimited evidence exists on the impact of age and comorbidity on biopsy rates and findings among older women. Materials and methodsWe used data from 170,657 women ages 66–94 enrolled in the United States Breast Cancer Surveillance Consortium (BCSC). We estimated one-year rates of biopsy by type (any, fine-needle aspiration (FNA), core or surgical) and yield of the most invasive biopsy finding (benign, ductal carcinoma in situ (DCIS) and invasive breast cancer) by age and comorbidity. Statistical significance was assessed using Wald statistics comparing coefficients estimated from logistic regression models adjusted for age, comorbidity, BCSC registry, and interaction between age and comorbidity. ResultsOf 524,860 screening mammograms, 9830 biopsies were performed following 7930 exams (1.5%) within one year, specifically 5589 core biopsies (1.1%), 3422 (0.7%) surgical biopsies and 819 FNAs (0.2%). Biopsy rates per 1000 screens decreased with age (66–74:15.7, 95%CI:14.8–16.8), 75–84:14.5(13.5–15.6), 85–94:13.2(11.3,15.4), ptrend < 0.001) and increased with Charlson Comorbidity Score (CCS = 0:14.4 (13.5–15.3), CCS = 1:16.6 (15.2–18.1), CCS ≥2:19.0 (16.9–21.5), ptrend < 0.001).Biopsy rates increased with CCS at ages 66–74 and 75–84 but not 85–94. Core and surgical biopsy rates increased with CCS at ages 66–74 only. For each biopsy type, the yield of invasive breast cancer increased with age irrespective of comorbidity. DiscussionWomen aged 66–84 with significant comorbidity in a breast cancer screening population had higher breast biopsy rates and similar rates of invasive breast cancer diagnosis than their counterparts with lower comorbidity. A considerable proportion of these diagnoses may represent overdiagnoses, given the high competing risk of death from non-breast-cancer causes among older women.

A Randomized Trial to Maximize Identification and Genetic Counseling Referral of Women at Risk for Hereditary Breast and Ovarian Cancer

Purpose: The Breast Cancer Genetics Referral Screening Tool (B-RST™) has been endorsed as one of several validated screening tools to identify women appropriate for cancer genetics referral. We conducted a randomized trial to determine the most effective means of follow-up for women who screened positive on B-RST™ 3.0. Methods: Women undergoing screening mammography at one of four Emory clinics were approached to complete the B-RST™. Participants who screened positive were randomized to one of three follow-up groups: self-referral (Group 1), electronic health record (EHR) clinician messaging (Group 2), or direct contact (Group 3). We compared genetic counseling appointment scheduling and completion rates by group. Results: Of 2,422 participants, 658 (27.2%) screened positive. Genetic counseling appointments were scheduled by 9.2%, 20.1% and 9.7% of Group 1, 2 and 3 participants respectively (p=0.001). Challenges to scheduling included lack of physician response to EHR messages and unsuccessful direct contact. Among those scheduled (n=78) 70.5% completed the appointment, with no difference between the three groups. Conclusion: B-RST™ can be used effectively in mammography settings to identify high-risk women for cancer genetics referral. Follow-up via EHR appears an acceptable and efficient approach, but additional strategies are needed to facilitate completion of the genetic counseling process.

Breast Density Awareness and Knowledge in a Mammography Screening Cohort of Predominantly Hispanic Women: Does Breast Density Notification Matter?

New York State law mandates that women with dense breasts receive a written notification of their breast density (BD) and its implications, but data on the impact of dense breast notification (DBN) on BD awareness and knowledge in diverse populations remain limited. Between 2016 and 2018, we collected survey and mammographic data from 666 women undergoing screening mammography in New York City (ages 40-60, 80% Hispanic, 69% Spanish-speaking) to examine the impact of prior DBN on BD awareness by sociodemographic and breast cancer risk factors, and describe BD knowledge by sources of information. Only 24.8% of the overall sample and 34.9% of women receiving DBN had BD awareness. In multivariable models adjusting for DBN, awareness was significantly lower in women who were Spanish-speaking [OR, 0.16; 95% confidence interval (CI), 0.09-0.30 vs. English speakers], were foreign-born (OR, 0.31; 95% CI, 0.16-0.58 vs. U.S.-born), and had lower educational attainment (e.g., high school degree or less; OR, 0.14; 95% CI, 0.08-0.26 vs. college or higher degree). Women receiving DBN were more likely to be aware of BD (OR, 2.61; 95% CI, 1.59-4.27) but not more knowledgeable about the impact of BD on breast cancer risk and detection. However, women reporting additional communication about their BD showed greater knowledge in these areas. DBN increases BD awareness disproportionately across sociodemographic groups. Efforts to improve communication of DBN must focus on addressing barriers in lower socioeconomic and racially and ethnically diverse women, including educational and language barriers.

Risk factors for breast cancer subtypes among Black women undergoing screening mammography.

Black women are more likely than non-Hispanic White women to be diagnosed with triple negative breast cancer (TNBC), an aggressive subtype with limited treatment options. The study objective was to evaluate the associations of known breast cancer risk factors, including breast density, with TNBC among Black women. This study included Black women who underwent screening mammography between the ages of 40-84years at a University of Pennsylvania Health System between 2010 and 2015. Cox proportional hazard models using multiple imputation with chained equations were used to estimate hazard ratios and 95% confidence intervals for risk factors for ER/PR+/HER2- and TNBC. Among 25,013 Black women, there were 330 incident breast cancers (1.3%) during a mean follow-up of 5.8years; 218 (66.1%) ER/PR+ HER- and 61 (18.1%) TNBC. Having dense breasts (heterogeneously dense or extremely dense) vs. non-dense breasts (almost entirely fatty or scattered areas of fibroglandular density) increased risk of ER/PR+/HER2- breast cancer almost 80% (HR 1.79, 95% CI 1.32-2.43) and TNBC more than twofold (HR 2.53, 1.45-4.44). Older age was associated with an increased risk for ER/PR+/HER2- (HR 1.04, 1.03-1.06) and TNBC (HR 1.03, 1.00-1.05). Having a BMI of > 30kg/m2 was associated with an increased risk (HR 2.77, 1.05-7.30) for TNBC and an increased risk of ERPR+/HER2- breast cancer in postmenopausal but not pre-menopausal women (p-interaction = 0.016). Our results suggest that breast density and obesity are strong risk factors for TNBC among Black women. Understanding breast cancer subtype specific risk factors among Black women can help improve risk assessment.

Cost-Sharing and Out-of-Pocket Cost for Women Who Received MRI for Breast Cancer Screening.

The financial protection of the prevention provision of the Affordable Care Act (ACA) doesn't apply to breast MRI but only to mammography for breast cancer screening. The purpose of the study is to examine the financial burden among women who received breast magnetic resonance imaging (MRI) for screening. This observational study used the Marketscan database. Women who underwent breast MRI between 2009 and 2017 and had screening mammography within 6 months of the MRI were included. We compared the time trend of the proportion of zero cost-share for women undergoing screening mammography and that for MRI. We quantified out-of-pocket (OOP) costs as the sum of copayment, coinsurance, and deductible and defined zero cost-share as having no OOP cost. We conducted multivariable logistic regression and 2-part model to examine factors associated with zero cost-share and OOP costs of MRI, respectively. During the study period, 16 341 women had a screening breast MRI. The proportion of screening MRI claims with zero cost-share decreased from 43.1% (2009) to 26.2% (2017). The adjusted mean OOP cost for women in high-deductible plans was more than twice the cost for their counterparts ($549 vs $251; 2-sided P < .001). Women who resided in the South in the post-Affordable Care Act era were less likely to have zero cost-share and paid higher OOP costs for screening MRI. Many women are subject to high financial burden when receiving MRI for breast cancer screening. Those enrolled in high-deductible plans and who reside in the South are especially vulnerable financially.

Distribution of Estimated Lifetime Breast Cancer Risk Among Women Undergoing Screening Mammography.

OBJECTIVE. Supplemental screening breast MRI is recommended for women with an estimated lifetime risk of breast cancer of greater than 20-25%. The performance of risk prediction models varies for each individual and across groups of women. The present study investigates the concordance of three breast cancer risk prediction models among women presenting for screening mammography. SUBJECTS AND METHODS. In this prospective study, we calculated the estimated lifetime risk of breast cancer using the modified Gail, Tyrer-Cuzick version 7, and BRCAPRO models for each woman who presented for screening mammography. Per American Cancer Society guidelines, for each woman the risk was categorized as less than 20% or 20% or greater as well as less than 25% or 25% or greater with use of each model. Venn diagrams were constructed to evaluate concordance across models. The McNemar test was used to test differences in risk group allocations between models, with p ≤ .05 considered to denote statistical significance. RESULTS. Of 3503 screening mammography patients who underwent risk stratification, 3219 (91.9%) were eligible for risk estimation using all three models. Using at least one model, 440 (13.7%) women had a lifetime risk of 20% or greater, including 390 women (12.1%) according to the Tyrer-Cuzick version 7 model, 18 (0.6%) according to the BRCAPRO model, and 141 (4.4%) according to the modified Gail model. Six women (0.2%) had a risk of 20% or greater according to all three models. Women were significantly more likely to be classified as having a high lifetime breast cancer risk by the Tyrer-Cuzick version 7 model compared with the modified Gail model, with thresholds of 20% or greater (odds ratio, 6.4; 95% CI, 4.7-8.7) or 25% or greater (odds ratio, 7.4; 95% CI, 4.7-11.9) used for both models. CONCLUSION. To identify women with a high lifetime breast cancer risk, practices should use estimates of lifetime breast cancer risk derived from multiple risk prediction models.

Women screened for breast cancer are dying from lung cancer: An opportunity to improve lung cancer screening in a mammography population.

Lung cancer is the leading cancer killer in women, resulting in more deaths than breast, cervical and ovarian cancer combined. Screening for lung cancer has been shown to significantly reduce mortality, with some evidence that women may have a greater benefit. This study demonstrates that a population of women being screened for breast cancer may greatly benefit from screening for lung cancer. Data from 18,040 women who were screened for breast cancer in 2015 at two imaging facilities that also performed lung screening were reviewed. A natural language-processing algorithm followed by a manual chart review identified women eligible for lung cancer screening by U.S. Preventive Services Task Force (USPSTF) criteria. A chart review of these eligible women was performed to determine subsequent enrollment in a lung screening program (2016-2019), current screening eligibility, cancer diagnoses and cancer-related outcomes. Natural language processing identified 685 women undergoing screening mammography who were also potentially eligible for lung screening based on age and smoking history. Manual chart review confirmed 251 were eligible under USPSTF criteria. By June 2019, 63 (25%) had enrolled in lung screening, of which three were diagnosed with screening-detected lung cancer resulting in zero deaths. Of 188 not screened, seven were diagnosed with lung cancer resulting in five deaths by study end. Four women received a diagnosis of breast cancer with no deaths. Women screened for breast cancer are dying from lung cancer. We must capitalize on reducing barriers to improve screening for lung cancer among high-risk women.

Abstract PO-238: Breast density knowledge and awareness among Latinas in a low-resource setting: A comparison nationally-representative sample of Latinas

Abstract Objective: Breast density notification laws aim to increase women’s awareness and knowledge about breast density (BD). This study’s aim was to compare BD knowledge and awareness in two Hispanic populations: a safety-net clinic serving Latina population in Maricopa County, Arizona (AZ) and a national sample of Hispanic women participating in an online research panel. Materials/Methods: Women ages 40-74 were recruited at the AZ clinic from 2016-2019 at a screening mammography appointment as part of a larger clinical trial (AZ cohort). Surveys were completed in person (English or Spanish) at enrollment to assess awareness of BD, understanding of BD risk, and mammography history. The same questions were asked in a nationally representative online panel survey conducted in 2017. All data from the national survey were weighted to adjust for probability of selection into the panel and post-stratified to match known U.S. Hispanic population distributions (NS cohort). Univariate comparisons between the clinic and the national panel were performed using Rao-Scott chi-square tests. Associations with awareness and correct knowledge were examined with multivariable logistic regression. All summaries and analyses are weighted, and were performed with SAS version 9.4 SURVEY procedures (SAS Institute Inc., Cary, NC). Results: The analysis included 1332 Hispanic women from the AZ clinic and 152 Hispanic women who completed the national survey. The AZ cohort was younger (mean age: 48.5 vs 52.8), had less education (less than high school: 68.7% vs 34.8% less than high school), more likely to prefer Spanish (92.3% vs 53.1%) and less likely to have had a prior mammogram as compared NS cohort (82.8% vs 90.4%) (all p≤ 0.03). NS cohort was more likely to have awareness of BD (32.6% vs 20.7%); correct understanding of the masking effect of BD, (67.8% vs 37.0%,) and breast cancer risk (72.2% vs 32.6%,), compared to the AZ cohort (all p &amp;lt; 0.004). When adjusted for differences in education, age, language, and screening mammography history, BD awareness was similar between the two cohorts (adjusted odds ratio [ORadj] 0.95, p=0.83). Awareness was positively associated with more education, previous mammogram history, and English language. However, differences in BD knowledge remained (ORadj=2.8 [p=0.03] and 7.2 [P&amp;lt;0.001] for knowledge of masking and risk, respectively). Conclusions: There were significant differences in BD awareness and knowledge between a nationally-representative sample of Latinas and Latinas in a low-resource setting. The differences in BD awareness, but not knowledge, could be explained by education, screening history and preferred language. These findings suggest that a one-size-fits-all approach to raising BD awareness and knowledge will not work. To ensure equitable dissemination of health care to Latina women undergoing screening mammography, future work should be aimed at developing effective tools and resources for educating Spanish-speaking women about BD and risk-based screening. Citation Format: Jillian Leaver, Bhavika K. Patel, Jennifer L. Ridgeway, Sarah Jenkins, Vera Suman, Deborah J. Rhodes, Aaron Norman, Karthik Ghosh, Bijan Borah, Carrie Hruska, Edna Ramos, Davinder Singh, Matt Jewett, Carmen Radecki-Breitkof, Celine Vachon. Breast density knowledge and awareness among Latinas in a low-resource setting: A comparison nationally-representative sample of Latinas [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-238.

Breast Cancer Screening Among Medically Underserved Women in New Mexico: Potential for Lower Recall Rates with Digital Breast Tomosynthesis.

Introduction: Digital breast tomosynthesis (DBT) may decrease recall rates (RRs) and improve positive predictive values (PPVs) and cancer detection rates (CDRs) versus full-field digital mammography (FFDM). The value of DBT has not been assessed in New Mexico's rural and minority population. Objectives of this study were to compare RRs, CDRs, and PPVs using FFDM+DBT versus FFDM in screening mammograms at the University of New Mexico between 2013 and 2016 and to qualitatively evaluate patient decision-making regarding DBT. Materials and Methods: RRs, CDRs, and PPVs with 95% confidence intervals and relative risk were calculated from 35,147 mammograms. The association between relative risk and mammography approach was tested using Pearson's chi-square test. Twenty women undergoing screening were interviewed for qualitative evaluation of decision-making. Results: From 2013 to 2016, RRs were 8.4% and 11.1% for FFDM+DBT and FFDM, respectively. The difference in RRs became more pronounced with time. No significant difference was observed in PPVs or CDRs. Qualitative interviews revealed that the majority had limited prior knowledge of DBT and relied on provider recommendations. Conclusion: In New Mexico women undergoing screening mammography, a 30% relative risk reduction in RRs was observed with FFDM+DBT. Qualitative interviews suggest that women are aware of and receptive to DBT, assuming adequate educational support. Clinical Trials.gov ID: NCT03979729.

The Role of Social Determinants of Health in Self-Reported Access to Health Care Among Women Undergoing Screening Mammography.

Background: Social determinants of health (SDOH) contribute to health care disparities, with social and economic barriers often leading to difficulties in obtaining necessary care. We evaluated barriers to receiving health care, focusing on caretaker responsibilities, health insurance and cost, and transportation. Materials and Methods: We included women ages ≥40 years receiving screening mammography across three Breast Cancer Surveillance Consortium registries from 2012 to 2017. Women self-reported social and financial barriers to receiving health care in the 12 months before their screening mammogram. We evaluated woman- and census-based community-level factors associated with reporting a barrier using multivariate logistic regression. We assessed interaction with urban versus nonurban residence using Wald tests. Results: Among 393,430 women, 3.6% reported a barrier with a higher proportion in urban versus nonurban settings (3.9% [n = 11,977] vs. 2.2% [n = 1,655], respectively; p < 0.001). Among women reporting a barrier, health care cost and/or no insurance was the most common (49.3%), and no transportation was the least common (7.8%). Compared with white women, odds of reporting barriers were higher among black (adjusted odds ratio [aOR] = 1.30, 95% confidence interval [CI]: 1.16-1.44), Hispanic (aOR = 1.66, 95% CI: 1.53-1.80), and other race (aOR = 1.84, 95% CI: 1.65-2.04) women. Barriers were less likely in women with higher median household income (aOR = 0.69, 95% CI: 0.61-0.79) or higher average health insurance costs (aOR = 0.85, 95% CI: 0.74-0.98), but were more likely in high diversity index areas (aOR = 1.28, 95% CI: 1.11-1.48). Conclusions: Social and financial barriers exist based on race/ethnicity and SDOH related to income, insurance costs, and place of residence among women undergoing screening mammography. Breast imaging facilities could utilize information on these barriers to improve biennial screening adherence or ensure that women with abnormal findings obtain appropriate follow-up care through targeted interventions.

Multimodality Imaging of Ductal Carcinoma In Situ

We aim to review the appearance of ductal carcinoma in situ (DCIS) across the spectrum of imaging modalities used in common clinical practice. Changes in technology and clinical breast cancer screening patterns have impacted the imaging evaluation of DCIS. DCIS classically presents as asymptomatic calcifications in women undergoing screening mammography. The replacement of traditional 2D mammography with digital breast tomosynthesis has changed the typical appearance of screen-detected DCIS. Ultrasound is traditionally utilized to detect DCIS in women with clinical symptoms, but efforts to increase screening ultrasound rates for women with dense breasts makes it more important to identify the appearance of DCIS in asymptomatic women. Improvements in MRI technology have made MRI the most sensitive imaging modality to detect DCIS and define the extent of disease, which is increasingly important given greater utilization of MRI for high-risk screening and determination of extent of known disease. Finally, the emergence of active surveillance, or non-surgical management, for DCIS has increased the focus on presurgical identification of associated invasive cancer, with early results demonstrating promise via computer vision and deep learning approaches for this task. DCIS has a highly variable imaging appearance which is subject to changes in imaging technology and clinical management.