Background. Breast density is an important risk factor for breast cancer and is known to be associated with characteristics such as age, race, and hormone levels; however, it is unclear what factors contribute to changes in breast density in postmenopausal women over time. Understanding factors associated with density changes may enable a better understanding of breast cancer risk and facilitate potential strategies for prevention. Methods. This study investigated potential associations between personal factors and changes in mammographic density in a cohort of 3,392 postmenopausal women with no personal history of breast cancer between 2011 and 2017. Self-reported information on demographics, breast and reproductive history, and lifestyle factors, including body mass index (BMI), alcohol intake, smoking, and physical activity, was collected by an electronic intake form, and breast imaging reporting and database system (BI-RADS) mammographic density scores were obtained from electronic medical records. Factors associated with a longitudinal increase or decrease in mammographic density were identified using Fisher’s exact test and multivariate conditional logistic regression. Results. 7.9% of women exhibited a longitudinal decrease in mammographic density, 6.7% exhibited an increase, and 85.4% exhibited no change. Longitudinal changes in mammographic density were correlated with age, race/ethnicity, and age at menopause in the univariate analysis. In the multivariate analysis, Asian women were more likely to exhibit a longitudinal increase in mammographic density and less likely to exhibit a decrease compared to White women. On the other hand, obese women were less likely to exhibit an increase and more likely to exhibit a decrease compared to normal weight women. Women who underwent menopause at age 55 years or older were less likely to exhibit a decrease in mammographic density compared to women who underwent menopause at a younger age. Besides obesity, lifestyle factors (alcohol intake, smoking, and physical activity) were not associated with longitudinal changes in mammographic density. Conclusions. The associations we observed between Asian race/obesity and longitudinal changes in BI-RADS density in postmenopausal women are paradoxical in that breast cancer risk is lower in Asian women and higher in obese women. However, the association between later age at menopause and a decreased likelihood of decreasing in BI-RADS density over time is consistent with later age at menopause being a risk factor for breast cancer and suggests a potential relationship between greater cumulative lifetime estrogen exposure and relative stability in breast density after menopause. Our findings support the complexity of the relationships between breast density, BMI, hormone exposure, and breast cancer risk.

The Breast JournalVolume 27, Issue 2 p. 111-112 EDITORIAL Prospects for the use of automated whole breast ultrasound: In planning and monitoring breast cancer treatment Stephen A. Feig MD, Corresponding Author Stephen A. Feig MD sfeig@uci.edu Clinical Radiology, Radiological Sciences School of Medicine, UC Irvine, Irvine, CA, USA Correspondence Stephen A. Feig, Clinical Radiology, Radiological Sciences School of Medicine, UC Irvine, Irvine, CA, USA. Email: sfeig@uci.eduSearch for more papers by this author Stephen A. Feig MD, Corresponding Author Stephen A. Feig MD sfeig@uci.edu Clinical Radiology, Radiological Sciences School of Medicine, UC Irvine, Irvine, CA, USA Correspondence Stephen A. Feig, Clinical Radiology, Radiological Sciences School of Medicine, UC Irvine, Irvine, CA, USA. Email: sfeig@uci.eduSearch for more papers by this author First published: 01 February 2021 https://doi.org/10.1111/tbj.14181Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume27, Issue2February 2021Pages 111-112 RelatedInformation

OBJECTIVE:To determine the impact of the COVID-19 pandemic on breast imaging education.METHODS:A 22-item survey addressing four themes during the early pandemic (time on service, structured education, clinical training, future plans) was emailed to Society of Breast Imaging members and members-in-training in July 2020. Responses were compared using McNemar's and Mann-Whitney U tests; a general linear model was used for multivariate analysis.RESULTS:Of 136 responses (136/2824, 4.8%), 96 U.S. responses from radiologists with trainees, residents, and fellows were included. Clinical exposure declined during the early pandemic, with almost no medical students on service (66/67, 99%) and fewer clinical days for residents (78/89, 88%) and fellows (48/68, 71%). Conferences shifted to remote live format (57/78, 73%), with some canceled (15/78, 19%). Compared to pre-pandemic, resident diagnostic (75/78, 96% vs 26/78, 33%) (P < 0.001) and procedural (73/78, 94% vs 21/78, 27%) (P < 0.001) participation fell, as did fellow diagnostic (60/61, 98% vs 47/61, 77%) (P = 0.001) and procedural (60/61, 98% vs 43/61, 70%) (P < 0.001) participation. Most thought that the pandemic negatively influenced resident and fellow screening (64/77, 83% and 43/60, 72%, respectively), diagnostic (66/77, 86% and 37/60, 62%), and procedural (71/77, 92% and 37/61, 61%) education. However, a majority thought that decreased time on service (36/67, 54%) and patient contact (46/79, 58%) would not change residents' pursuit of a breast imaging fellowship.CONCLUSION:The pandemic has had a largely negative impact on breast imaging education, with reduction in exposure to all aspects of breast imaging. However, this may not affect career decisions.

HomeRadiologyVol. 299, No. 3 PreviousNext Reviews and CommentaryFree AccessEditorialInfluence of Patient Participation on Decreased Mortality from Screening MammographyStephen A. Feig Stephen A. Feig Author AffiliationsFrom the Department of Radiology, University of California, Irvine Medical Center, 101 City Drive South, Route 140, Orange, CA 92868-3298.Address correspondence to the author (e-mail: [email protected]).Stephen A. Feig Published Online:Mar 30 2021https://doi.org/10.1148/radiol.2021210226MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Duffy and Tabár et al in this issue.Dr Feig is professor and division chief of breast imaging at University of California Irvine. His research interests include calculation of benefits, cost-effectiveness, and hypothetical risks from screening and development of multimodality screening guidelines. He has been awarded the gold medal from the Society of Breast Imaging.Download as PowerPointOpen in Image Viewer The Swedish Nine-County Service Screening Study (from 1992 to 2016) (1) was a public health measure performed after the success of the Swedish Two-County Randomized Clinical Trial (RCT) of mammography screening. RCTs such as the Two-County Trial (from 1978 to 1987) had to be performed first to provide proof that screening can reduce breast cancer mortality (2).Randomized trials consist of study and control groups. The two groups are carefully matched in every possible way, except the study group is offered screening and the control group is not. To avoid bias, RCTs measure breast cancer death rates rather than survival or incidence rates. Furthermore, RCTs are designed to avoid lead-time bias, length bias sampling, and selection bias. Lead-time bias refers to the possibility that screening finds breast cancers earlier but does not alter the time of death. Length bias sampling postulates that some cancers detected at screening are slower growing, less aggressive, and may never cause death if undetected. Selection bias refers to the possibility that women who volunteer for screening may have better health or better socioeconomic status than those who do not volunteer. Finally, faster growth rates for interval cancers missed at screening may negate more favorable survival rates for screen-detected cancers. The use of breast cancer mortality rates in a well-designed randomized trial avoids all these potential biases.Despite these advantages, RCTs may underestimate the true benefit from screening for two reasons: (a) some women in the study group may not agree to undergo screening (noncompliance) and (b) some women in the control group may obtain screening on their own, outside of the trial (contamination). Thirty-year follow-up of the Swedish Two-County Trial now shows a 31% mortality reduction among women aged 40–74 years in the study group offered screening compared with the control group not offered screening (3). However, even such long-term follow-up may underestimate the potential benefit from screening mammography (2).In this issue of Radiology, Duffy and colleagues (4) use data from the Swedish Nine-County Service Screening Study to estimate the potential benefit based on a woman’s participation in the last two screening rounds (1,4). In the study by Duffy et al, women aged 40–54 years could undergo screening as often as every 18 months, whereas those aged 55–69 years could undergo screening as often as every 24 months. These women were classified according to their participation in their last two potential screening rounds. Serial participants participated in both of the last two screening rounds. Intermittent participants attended the last but not the next to last screening round. Lapsed participants attended the next to last but not the last screening round. Serial nonparticipants did not attend either of the last two screening rounds.The women in the Swedish Nine-County Service Screening Study were followed for 10 years. For each of the four types of participation categories, the incidence rates per 100 000 person-years of cancers proving fatal within 10 years after diagnosis were measured. The relative risk (RR) was calculated according to participation status. Relative risk was lowest (0.50) for serial participants and highest (1.00) for nonparticipants. Intermittent participants and lapsed participants had relative risks of 0.64 and 0.75, respectively. The estimated 50% mortality reduction observed among serial participants who were actually screened was substantially higher than the 31% mortality reduction observed among study group women in the Swedish Two-County Trial who were offered screening but who may not have participated (3). Thus, the Swedish Nine-County Service Screening Study probably provides a more accurate index of the benefit to women who are actually screened. The cumulative mortality curves of the Swedish Two-County Randomized Trial 30-year follow-up and the Swedish Nine-County Service Screening study 24-year follow-up both diverge from their inception over time. It is clear that both of these studies indicate a substantial long-term benefit from screening.Because randomized trials compare breast cancer deaths between carefully matched study group women who are offered screening and control group women who are not offered screening, these trials are not affected by any bias due to confounding factors, such as socioeconomic status or comorbidities.Adjustments must be made for self-selection bias in the relative risks associated with each of the serial, intermittent, and lapsed participation categories in the Swedish Nine-County Service Screening Trial. Duffy and colleagues used their own method and made adjustments in the relative risks of dying from cancer in these participation categories, which indicate a relative risk of 1.07 for breast cancer deaths unrelated to the screening process (3). Furthermore, an adjustment of 1.03 was made for cancers that were fatal within 10 years of diagnosis in Northern Sweden using the estimate of Jonsson et al (4). Duffy et al discuss the rationale and methods used for this adjustment in their article. All these adjustments were extremely small and do not affect the basic conclusion of the study that compliance with screening recommendations has a major impact on mortality reduction.Eight randomized trials were conducted in Europe and North America between 1963 and 2005 (2,3,5). Mortality reduction for seven of these trials ranged from 17% to 31%. The Canadian National Breast Cancer Screening Study showed no benefit due to issues with technical quality and randomization (6). There are reasons why all these trials underestimated the benefit from screening by today’s standards. These include improvements in technical quality due to digital mammography and digital tomosynthesis. Many of these trials used one mammographic view instead of two for some screening rounds. Many screening intervals were too long. Screening frequency ranged from 12 to 33 months. Estimates show that greater benefit would have resulted from annual screening, especially for women aged 40–49 years who have faster breast cancer growth. Michaelson et al (7) used a tumor growth rate model to calculate that annual screening would result in a 51% reduction in distant metastatic disease compared with a 22% reduction with a screening interval of 2 years.Estimates indicate that the use of annual screening for the Swedish Two-County Trial could have resulted in an additional 18% mortality reduction for women aged 40–49 years who underwent screening every 2 years and an additional 12% mortality reduction in women aged 50–59 years who underwent screening every 33 months (8).Several investigators have used mathematic models of actual RCT data to calculate benefit for an average woman screened every year and for whom results are not affected by noncompliance or contamination. For example, on the basis of an observed 45% reduction in breast cancer mortality among women aged 39–49 years offered screening every 18 months in the Gothenburg Trial, Feig (9) calculated that the mortality reduction could have been even higher. With 85% compliance, it could have been as high as 65% with annual screening. For 100% compliance, it could have been as high as 75% with annual screening.Screening frequency and length of follow-up should be sufficient to reach a steady state at which the greatest mortality reduction will be apparent. Miettinen et al (10) showed that for women aged 55–69 years at entry into the Malmo Mammographic Screening Trial, mortality reduction was highest between 8 and 11 years of follow-up. For that period, they calculated a 55% reduction in breast cancer deaths. That value was much higher than the 26% mortality reduction reported by Andersson and Nystrom, who included data from before year 8 when the benefit had not yet peaked and from after year 11 when the benefit was being diluted (10).Finally, a study of women aged 40–69 years enrolled in two of the Swedish service screening programs between 1988 and 1996 showed a 63% reduction in death rates from breast cancer among screened women and a 48% reduction among those invited to screening (2). A meta-analysis of seven European service screening studies found a breast cancer mortality reduction of 25% among those invited versus those not invited to screening and a reduction of 38% among those screened versus not screened (2). Among the women enrolled in the seven European case-controlled service screening studies, there was a 31% mortality reduction among invited women versus not invited women and a 52% mortality reduction among those who underwent screening versus those who did not undergo screening (2).Results from these many service screening studies indicate that when women fully participate, non–research-organized service screening studies can obtain and exceed the reductions in breast cancer mortality found in randomized trials. Further advances in mammographic technology and optimizations in screening frequency and length will allow even greater benefits.Disclosures of Conflicts of Interest: S.A.F. disclosed no relevant relationships.References1. Duffy SW, Tabár L, Yen AM, et al. Mammography screening reduces rates of advanced and fatal breast cancers: Results in 549 091 women. Cancer 2020;126(13):2971–2979. Crossref, Medline, Google Scholar2. Feig SA. Screening mammography benefit controversies: sorting the evidence. Radiol Clin North Am 2014;52(3):455–480. Crossref, Medline, Google Scholar3. Tabár L, Vitak B, Chen THH, et al. Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology 2011;260(3):658–663. Link, Google Scholar4. Duffy SW, Tabár L, Yen AM, et al. Beneficial Effect of Consecutive Screening Mammography Examinations on Mortality from Breast Cancer: A Prospective Study. Radiology 2021. https://doi.org/10.1148/radiol.2021203935. Published online March 2, 2021. Google Scholar5. Duffy SW, Vulkan D, Cuckle H, et al. Effect of mammographic screening from age 40 years on breast cancer mortality (UK Age trial): final results of a randomised, controlled trial. Lancet Oncol 2020;21(9):1165–1172. Crossref, Medline, Google Scholar6. Kopans DB, Feig SA. The Canadian National Breast Screening Study: a critical review. AJR Am J Roentgenol 1993;161(4):755–760. Crossref, Medline, Google Scholar7. Michaelson JS, Halpern E, Kopans DB. Breast cancer: computer simulation method for estimating optimal intervals for screening. Radiology 1999;212(2):551–560. Link, Google Scholar8. Feig SA. Estimation of currently attainable benefit from mammographic screening of women aged 40-49 years. Cancer 1995;75(10):2412–2419. Crossref, Medline, Google Scholar9. Feig SA. Increased benefit from shorter screening mammography intervals for women ages 40-49 years. Cancer 1997;80(11):2035–2039. Crossref, Medline, Google Scholar10. Miettinen OS, Henschke CI, Pasmantier MW, Smith JP, Libby DM, Yankelevitz DF. Mammographic screening: no reliable supporting evidence?. Lancet 2002;359(9304):404–405. Crossref, Medline, Google ScholarArticle HistoryReceived: Jan 25 2021Revision requested: Feb 5 2021Revision received: Feb 22 2021Accepted: Mar 2 2021Published online: Mar 30 2021Published in print: June 2021 FiguresReferencesRelatedDetailsAccompanying This ArticleBeneficial Effect of Consecutive Screening Mammography Examinations on Mortality from Breast Cancer: A Prospective StudyMar 2 2021RadiologyRecommended Articles Breast Cancer Risk Prediction Using Deep LearningRadiology2021Volume: 301Issue: 3pp. 559-560Identifying Effective Supplemental Screening Strategies for Women with a Personal History of Breast CancerRadiology2020Volume: 295Issue: 1pp. 64-65Addressing Racial Inequities in Access to State-of-the-Art Breast ImagingRadiology2022Volume: 306Issue: 2Comparative Benefit-to–Radiation Risk Ratio of Molecular Breast Imaging, Two-Dimensional Full-Field Digital Mammography with and without Tomosynthesis, and Synthetic Mammography with TomosynthesisRadiology: Imaging Cancer2019Volume: 1Issue: 1Does Reader Performance with Digital Breast Tomosynthesis Vary according to Experience with Two-dimensional Mammography?Radiology2017Volume: 283Issue: 2pp. 371-380See More RSNA Education Exhibits High Risk Breast Cancer Screening  Digital Posters2020Let’s Talk about Next-Generation Breast Cancer Screening Programs: How Should We Do? What Should We Use?Digital Posters2020Breast Imaging Controversies In The Elderly PopulationDigital Posters2021 RSNA Case Collection Deodorant ArtifactRSNA Case Collection2021Slow-growing cancerRSNA Case Collection2020Invasive Lobular CarcinomaRSNA Case Collection2021 Vol. 299, No. 3 Metrics Altmetric Score PDF download

Objective: To determine the early impact of the COVID-19 pandemic on breast imaging centers in California and Texas and compare regional differences. Methods: An 11-item survey was emailed to American College of Radiology accredited breast imaging facilities in California and Texas in August 2020. A question subset addressed March-April government restrictions on elective services ("during the shutdown" and "after reopening"). Comparisons were made between states with chi-square and Fisher's tests, and timeframes with McNemar's and paired t-tests. Results: There were 54 respondents (54/240, 23%, 26 California, 28 Texas). Imaging volumes fell during the shutdown and remained below pre-pandemic levels after reopening, with reduction in screening greatest (ultrasound 12% of baseline, mammography 13%, MRI 23%), followed by diagnostic MRI (43%), procedures (44%), and diagnostics (45%). California reported higher volumes during the shutdown (procedures, MRI) and after reopening (diagnostics, procedures, MRI) versus Texas (P=0.001-0.02). Most screened patients (52/54, 96% symptoms and 42/54, 78% temperatures), and 100% (53/53) modified check-in and check-out. Reading rooms or physician work were altered for social distancing (31/54, 57%). Physician mask (45/48, 94%), gown (15/48, 31%), eyewear (22/48, 46%), and face shield (22/48, 46%) use during procedures increased after reopening versus pre-pandemic (P<0.001-0.03). Physician (47/54, 87%) and staff (45/53, 85%) financial impacts were common, but none reported terminations. Conclusion: Breast imaging volumes during the early pandemic fell more severely in Texas than in California. Safety measures and financial impacts on physicians and staff were similar in both states.

The majority of randomized control trials and service-based screening studies of women ages 40-49 years demonstrate reductions in mortality of 29%-48% when long-term outcome is assessed. Annual screening is preferable in these younger women due to faster tumor-doubling times. Advances in mammography technique and breast ultrasound may allow even better results in the future.

OBJECTIVE We hypothesize that radiologists' estimated percentage likelihood assessments for the presence of ductal carcinoma in situ (DCIS) and invasive cancer may predict histologic outcomes. MATERIALS AND METHODS Two hundred fifty cases categorized as BI-RADS category 4 or 5 at four University of California Medical Centers were retrospectively reviewed by 10 academic radiologists with a range of 1-39 years in practice. Readers assigned BI-RADS category (1, 2, 3, 4a, 4b, 4c, or 5), estimated percentage likelihood of DCIS or invasive cancer (0-100%), and confidence rating (1 = low, 5 = high) after reviewing screening and diagnostic mammograms and ultrasound images. ROC curves were generated. RESULTS Sixty-two percent (156/250) of lesions were benign and 38% (94/250) were malignant. There were 26 (10%) DCIS, 20 (8%) invasive cancers, and 48 (19%) cases of DCIS and invasive cancer. AUC values were 0.830-0.907 for invasive cancer and 0.731-0.837 for DCIS alone. Sensitivity of 82% (56/68), specificity of 84% (153/182), positive predictive value (PPV) of 66% (56/85), negative predictive value (NPV) of 93% (153/165), and accuracy of 84% ([56 + 153]/250) were calculated using an estimated percentage likelihood of 20% or higher as the prediction threshold for invasive cancer for the radiologist with the highest AUC (0.907; 95% CI, 0.864-0.951). Every 20% increase in the estimated percentage likelihood of invasive cancer increased the odds of invasive cancer by approximately two times (odds ratio, 2.4). For DCIS, using a threshold of 40% or higher, sensitivity of 81% (21/26), specificity of 79% (178/224), PPV of 31% (21/67), NPV of 97% (178/183), and accuracy of 80% ([21 + 178]/250) were calculated. Similarly, these values were calculated at thresholds of 2% or higher (BI-RADS category 4) and 95% or higher (BI-RADS category 5) to predict the presence of malignancy. CONCLUSION Using likelihood estimates, radiologists may predict the presence of invasive cancer with fairly high accuracy. Radiologist-assigned estimated percentage likelihood can predict the presence of DCIS, albeit with lower accuracy than that for invasive cancer.

The study aimed to determine the inter-observer agreement among academic breast radiologists when using the Breast Imaging Reporting and Data System (BI-RADS) lesion descriptors for suspicious findings on diagnostic mammography.Ten experienced academic breast radiologists across five medical centers independently reviewed 250 de-identified diagnostic mammographic cases that were previously assessed as BI-RADS 4 or 5 with subsequent pathologic diagnosis by percutaneous or surgical biopsy. Each radiologist assessed the presence of the following suspicious mammographic findings: mass, asymmetry (one view), focal asymmetry (two views), architectural distortion, and calcifications. For any identified calcifications, the radiologist also described the morphology and distribution. Inter-observer agreement was determined with Fleiss kappa statistic. Agreement was also calculated by years of experience.Of the 250 lesions, 156 (62%) were benign and 94 (38%) were malignant. Agreement among the 10 readers was strongest for recognizing the presence of calcifications (k = 0.82). There was substantial agreement among the readers for the identification of a mass (k = 0.67), whereas agreement was fair for the presence of a focal asymmetry (k = 0.21) or architectural distortion (k = 0.28). Agreement for asymmetries (one view) was slight (k = 0.09). Among the categories of calcification morphology and distribution, reader agreement was moderate (k = 0.51 and k = 0.60, respectively). Readers with more experience (10 or more years in clinical practice) did not demonstrate higher levels of agreement compared to those with less experience.Strength of agreement varies widely for different types of mammographic findings, even among dedicated academic breast radiologists. More subtle findings such as asymmetries and architectural distortion demonstrated the weakest agreement. Studies that seek to evaluate the predictive value of certain mammographic features for malignancy should take into consideration the inherent interpretive variability for these findings.

Rationale and Objectives: The study aimed to determine the inter-observer agreement among academic breast radiologists when using the Breast Imaging Reporting and Data System (BI-BADS) lesion descriptors for suspicious findings on diagnostic mammography.Materials and Methods: Ten experienced academic breast radiologists across five medical centers independently reviewed 250 de identified diagnostic mammographic cases that were previously assessed as BI-BADS 4 or 5 with subsequent pathologic diagnosis by percutaneous or surgical biopsy. Each radiologist assessed the presence of the following suspicious mammographic findings: mass, asymmetry (one view), focal asymmetry (two views), architectural distortion, and calcifications. For any identified calcifications, the radiologist also described the morphology and distribution. Inter-observer agreement was determined with Fleiss kappa statistic. Agreement was also calculated by years of experience.Results: Of the 250 lesions, 156 (62%) were benign and 94 (38%) were malignant. Agreement among the 10 readers was strongest for recognizing the presence of calcifications (k = 0.82). There was substantial agreement among the readers for the identification of a mass (k = 0.67), whereas agreement was fair for the presence of a focal asymmetry (k = 0.21) or architectural distortion (k = 0.28). Agreement for asymmetries (one view) was slight (k = 0.09). Among the categories of calcification morphology and distribution, reader agreement was moderate (k = 0.51 and k = 0.60, respectively). Readers with more experience (10 or more years in clinical practice) did not demonstrate higher levels of agreement compared to those with less experience.Conclusions: Strength of agreement varies widely for different types of mammographic findings, even among dedicated academic breast radiologists. More subtle findings such as asymmetries and architectural distortion demonstrated the weakest agreement. Studies that seek to evaluate the predictive value of certain mammographic features for malignancy should take into consideration the inherent interpretive variability for these findings.

Breast density notification laws, passed in 19 states as of October 2014, mandate that patients be informed of their breast density. The purpose of this study is to assess the impact of this legislation on radiology practices, including performance of breast cancer risk assessment and supplemental screening studies. A 20-question anonymous web-based survey was emailed to radiologists in the Society of Breast Imaging between August 2013 and March 2014. Statistical analysis was performed using Fisher's exact test. Around 121 radiologists from 110 facilities in 34 USA states and 1 Canadian site responded. About 50% (55/110) of facilities had breast density legislation, 36% of facilities (39/109) performed breast cancer risk assessment (one facility did not respond). Risk assessment was performed as a new task in response to density legislation in 40% (6/15) of facilities in states with notification laws. However, there was no significant difference in performing risk assessment between facilities in states with a law and those without (p < 0.831). In anticipation of breast density legislation, 33% (16/48), 6% (3/48), and 6% (3/48) of facilities in states with laws implemented handheld whole breast ultrasound (WBUS), automated WBUS, and tomosynthesis, respectively. The ratio of facilities offering handheld WBUS was significantly higher in states with a law than in states without (p < 0.001). In response to breast density legislation, more than 33% of facilities are offering supplemental screening with WBUS and tomosynthesis, and many are performing formal risk assessment for determining patient management.

This review article explores the issue of overdiagnosis in screening mammography. Overdiagnosis is the screen detection of a breast cancer, histologically confirmed, that might not otherwise become clinically apparent during the lifetime of the patient. While screening mammography is an imperfect tool, it remains the best tool we have to diagnose breast cancer early, before a patient is symptomatic and at a time when chances of survival and options for treatment are most favorable. In 2015, an estimated 231,840 new cases of breast cancer (excluding ductal carcinoma in situ) will be diagnosed in the United States, and some 40,290 women will die. Despite these data, screening mammography for women ages 40-69 has contributed to a substantial reduction in breast cancer mortality, and organized screening programs have led to a shift from late-stage diagnosis to early-stage detection. Current estimates of overdiagnosis in screening mammography vary widely, from 0% to upwards of 30% of diagnosed cancers. This range reflects the fact that measuring overdiagnosis is not a straightforward calculation, but usually one based on different sets of assumptions and often biased by methodological flaws. The recent development of tomosynthesis, which creates high-resolution, three-dimensional images, has increased breast cancer detection while reducing false recalls. Because the greatest harm of overdiagnosis is overtreatment, the key goal should not be less diagnosis but better treatment decision tools. (Population Health Management 2015;18:S3-S11).

OBJECTIVE Using a combination of performance measures, we updated previously proposed criteria for identifying physicians whose performance interpreting screening mammography may indicate suboptimal interpretation skills. MATERIALS AND METHODS In this study, six expert breast imagers used a method based on the Angoff approach to update criteria for acceptable mammography performance on the basis of two sets of combined performance measures: set 1, sensitivity and specificity for facilities with complete capture of false-negative cancers; and set 2, cancer detection rate (CDR), recall rate, and positive predictive value of a recall (PPV1) for facilities that cannot capture false-negative cancers but have reliable cancer follow-up information for positive mammography results. Decisions were informed by normative data from the Breast Cancer Surveillance Consortium (BCSC). RESULTS Updated combined ranges for acceptable sensitivity and specificity of screening mammography are sensitivity≥80% and specificity≥85% or sensitivity 75-79% and specificity 88-97%. Updated ranges for CDR, recall rate, and PPV1 are: CDR≥6 per 1000, recall rate 3-20%, and any PPV1; CDR 4-6 per 1000, recall rate 3-15%, and PPV1≥3%; or CDR 2.5-4.0 per 1000, recall rate 5-12%, and PPV1 3-8%. Using the original criteria, 51% of BCSC radiologists had acceptable sensitivity and specificity; 40% had acceptable CDR, recall rate, and PPV1. Using the combined criteria, 69% had acceptable sensitivity and specificity and 62% had acceptable CDR, recall rate, and PPV1. CONCLUSION The combined criteria improve previous criteria by considering the interrelationships of multiple performance measures and broaden the acceptable performance ranges compared with previous criteria based on individual measures.

Long-term follow-up of randomized trials provide the most accurate estimates of overdiagnosis. Estimates from follow-up of service screening studies are almost as accurate if there is sufficient adjustment for lead time and risk status. When properly analyzed data from both of these types of trials indicate that the rate of overdiagnosis at screening mammography is clinically negligible: 0-5%. Population trend studies are a potentially highly inaccurate means to estimate overdiagnosis. Most cases of DCIS detected at screening are medium and high grade with substantial potential to become an invasive disease. To avoid overtreatment, clinicians need to tailor their treatment of DCIS to the histologic and molecular characteristics of each case.

Personalized Screening for Breast Cancer: A Wolf in Sheep's Clothing?Stephen A. Feig1Audio Available | Share

Rationale and Objectives: The purpose of this study was to compare the precision of mammographic breast density measurement using radiologist reader assessment, histogram threshold segmentation, fuzzy C-mean segmentation, and spectral material decomposition.Materials and Methods: Spectral mammography images from a total of 92 consecutive asymptomatic women (aged 50-69 years) who presented for annual screening mammography were retrospectively analyzed for this study. Breast density was estimated using 10 radiologist reader assessment, standard histogram thresholding, fuzzy C-mean algorithm, and spectral material decomposition. The breast density correlation between left and right breasts was used to assess the precision of these techniques to measure breast composition relative to dual-energy material decomposition.Results: In comparison to the other techniques, the results of breast density measurements using dual-energy material decomposition showed the highest correlation. The relative standard error of estimate for breast density measurements from left and right breasts using radiologist reader assessment, standard histogram thresholding, fuzzy C-mean algorithm, and dual-energy material decomposition was calculated to be 1.95, 2.87, 2.07, and 1.00, respectively.Conclusions: The results indicate that the precision of dual-energy material decomposition was approximately factor of two higher than the other techniques with regard to better correlation of breast density measurements from right and left breasts.

Numerous clinical studies have confirmed that screening women age 40 years and older reduces breast cancer mortality by 30% to 50%. Several factors including faster breast cancer growth rates and lower breast cancer incidence among younger women, as well as shorter life expectancy and more comorbid conditions among older women, should also be considered in screening guidelines. Annual screening beginning at age 40 years and continuing with no upper age limit, as long as a woman has a life expectancy of at least 5 years and no significant comorbid conditions, is currently recommended.

HomeRadioGraphicsVol. 34, No. 4 PreviousNext Invited CommentaryInvited Commentary: Digital Breast Tomosynthesis—The Road AheadStephen A. FeigStephen A. FeigAuthor AffiliationsDepartment of Radiology, University of California Irvine Medical Center Orange, CaliforniaStephen A. FeigPublished Online:Jul 14 2014https://doi.org/10.1148/rg.344140140MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1. Feig SA. Image quality of screening mammography: effect on clinical outcome. AJR Am J Roentgenol 2002;178(4):805–807. Crossref, Medline, Google Scholar2. Feig SA. Screening mammography benefit controversies: sorting the evidence. Radiol Clin North Am (in press). Google Scholar3. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013;267(1):47–56. Link, Google Scholar4. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013;14(7):583–589. Crossref, Medline, Google Scholar5. Rose SL, Tidwell AL, Bujnoch LJ, Kushwaha AC, Nordmann AS, Sexton R Jr. Implementation of breast tomosynthesis in a routine screening practice: an observational study. AJR Am J Roentgenol 2013;200(6):1401–1408. Crossref, Medline, Google Scholar6. Haas BM, Kalra V, Geisel J, Raghu M, Durand M, Philpotts LE. Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening. Radiology 2013;269(3):694–700. Link, Google Scholar7. Rafferty EA, Park JM, Philpotts LE, et al. Assessing radiologist performance using combined digital mammography and breast tomosynthesis compared with digital mammography alone: results of a multicenter, multireader trial. Radiology 2013;266(1):104–113. Link, Google Scholar8. Roth RG, Maidment ADA, Weinstein SP, Roth SO, Conant EF. Digital breast tomosynthesis: lessons learned from early clinical implementation. RadioGraphics 2014;34(4):E89–E102. Link, Google Scholar9. Berg WA, Zhang Z, Lehrer D, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA 2012;307(13):1394–1404. Crossref, Medline, Google Scholar10. Hooley RJ, Greenberg KL, Stackhouse RM, Geisel JL, Butler RS, Philpotts LE. Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41. Radiology 2012;265(1):59–69. Link, Google Scholar11. Feig SA. Auditing and benchmarks in screening and diagnostic mammography. Radiol Clin North Am 2007;45(5):791–800, vi. Crossref, Medline, Google Scholar12. Gur D, Zuley ML, Anello MI, et al. 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Link, Google ScholarArticle HistoryPublished online: July 14 2014Published in print: July 2014 FiguresReferencesRelatedDetailsCited ByDigital Breast Tomosynthesis: Physics, Artifacts, and Quality Control ConsiderationsNikki Tirada, Guang Li, David Dreizin, Luke Robinson, Gauri Khorjekar, Sergio Dromi, Thomas Ernst, 15 February 2019 | RadioGraphics, Vol. 39, No. 2Breast Cancer Tissue Markers, Genomic Profiling, and Other Prognostic Factors: A Primer for RadiologistsNikki Tirada, Mireille Aujero, Gauri Khorjekar, Stephanie Richards, Jasleen Chopra, Sergio Dromi, Olga Ioffe, 12 October 2018 | RadioGraphics, Vol. 38, No. 7Overdiagnosis of Breast Cancer at Screening is Clinically InsignificantStephen A.Feig2015 | Academic Radiology, Vol. 22, No. 8Recommended Articles BI-RADS Category 3 Comparison: Probably Benign Category after Recall from Screening before and after Implementation of Digital Breast TomosynthesisRadiology2017Volume: 285Issue: 3pp. 778-787Recall and Outcome of Screen-detected Microcalcifications during 2 Decades of Mammography Screening in the Netherlands National Breast Screening ProgramRadiology2020Volume: 294Issue: 3pp. 528-537Digital Breast Tomosynthesis and Synthetic 2D Mammography versus Digital Mammography: Evaluation in a Population-based Screening ProgramRadiology2018Volume: 287Issue: 3pp. 787-794Implementation of Synthesized Two-dimensional Mammography in a Population-based Digital Breast Tomosynthesis Screening ProgramRadiology2016Volume: 281Issue: 3pp. 730-736Clinical Performance of Synthesized Two-dimensional Mammography Combined with Tomosynthesis in a Large Screening PopulationRadiology2017Volume: 283Issue: 1pp. 70-76See More RSNA Education Exhibits Breast Density Included in the Modern Rules of Mammographic ScreeningDigital Posters2019The Money Behind Mammo: A Dive Into The Finances Of Breast ImagingDigital Posters2021Integrating Digital Breast Tomosynthesis into a Hybrid Academic-Private PracticeDigital Posters2019 RSNA Case Collection Invasive Lobular CarcinomaRSNA Case Collection2021Ductal carcinoma in situRSNA Case Collection2020Primary breast amyloidosisRSNA Case Collection2020 Vol. 34, No. 4 Metrics Altmetric Score PDF download