Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women With Elevated Risk of Breast Cancer (vol 299, pg 2151, 2008)

American Radiology Services Inc, Johns Hopkins Green Spring, Lutherville, Maryland, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 06/2008; 299(18):2151-63. DOI: 10.1001/jama.299.18.2151
Source: PubMed


Screening ultrasound may depict small, node-negative breast cancers not seen on mammography.
To compare the diagnostic yield, defined as the proportion of women with positive screen test results and positive reference standard, and performance of screening with ultrasound plus mammography vs mammography alone in women at elevated risk of breast cancer.
From April 2004 to February 2006, 2809 women, with at least heterogeneously dense breast tissue in at least 1 quadrant, were recruited from 21 sites to undergo mammographic and physician-performed ultrasonographic examinations in randomized order by a radiologist masked to the other examination results. Reference standard was defined as a combination of pathology and 12-month follow-up and was available for 2637 (96.8%) of the 2725 eligible participants.
Diagnostic yield, sensitivity, specificity, and diagnostic accuracy (assessed by the area under the receiver operating characteristic curve) of combined mammography plus ultrasound vs mammography alone and the positive predictive value of biopsy recommendations for mammography plus ultrasound vs mammography alone.
Forty participants (41 breasts) were diagnosed with cancer: 8 suspicious on both ultrasound and mammography, 12 on ultrasound alone, 12 on mammography alone, and 8 participants (9 breasts) on neither. The diagnostic yield for mammography was 7.6 per 1000 women screened (20 of 2637) and increased to 11.8 per 1000 (31 of 2637) for combined mammography plus ultrasound; the supplemental yield was 4.2 per 1000 women screened (95% confidence interval [CI], 1.1-7.2 per 1000; P = .003 that supplemental yield is 0). The diagnostic accuracy for mammography was 0.78 (95% CI, 0.67-0.87) and increased to 0.91 (95% CI, 0.84-0.96) for mammography plus ultrasound (P = .003 that difference is 0). Of 12 supplemental cancers detected by ultrasound alone, 11 (92%) were invasive with a median size of 10 mm (range, 5-40 mm; mean [SE], 12.6 [3.0] mm) and 8 of the 9 lesions (89%) reported had negative nodes. The positive predictive value of biopsy recommendation after full diagnostic workup was 19 of 84 for mammography (22.6%; 95% CI, 14.2%-33%), 21 of 235 for ultrasound (8.9%, 95% CI, 5.6%-13.3%), and 31 of 276 for combined mammography plus ultrasound (11.2%; 95% CI. 7.8%-15.6%).
Adding a single screening ultrasound to mammography will yield an additional 1.1 to 7.2 cancers per 1000 high-risk women, but it will also substantially increase the number of false positives. Identifier: NCT00072501.

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    • "Conventional B-mode US is used as an adjunct to mammography for breast imaging to improve sensitivity [1]–[4]. However, B-mode US has shown low specificity in the differentiation of benign from malignant breast masses [5]–[9]. To increase specificity , breast masses are categorized according to the Breast Imaging-Reporting and Data System (BI-RADS) criteria defined by the American College of Radiology (ACR) [10], [11]. "
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    • "Almost 50% of women under the age of 50 have dense breasts [5] and could be potentially deemed undiagnosed after mammography screening [6], [7]. Ultrasound, along with mammography, has been proven to improve the sensitivity in palpable breast masses [4], [8], [9], but due to its low sensitivity towards nonpalpable and noncystic breast lesions, it is not used as a primary screening modality. Ultrasound is now widely used for supplementary screening in women with dense breasts, both by hand-held and automated modalities. "

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