[Show abstract][Hide abstract] ABSTRACT: Background: Magnetic resonance imaging (MRI) may guide breast cancer surgery by measuring residual tumor size post-neoadjuvant chemotherapy (NAC). Accurate measurement may avoid overly radical surgery or reduce the need for repeat surgery. This individual patient data (IPD) meta-analysis examines MRI's agreement with pathology in measuring the longest tumor diameter and compares MRI with alternative tests. Methods: A systematic review of MEDLINE, EMBASE, PREMEDLINE, Database of Abstracts of Reviews of Effects, Heath Technology Assessment, and Cochrane databases identified eligible studies. Primary study authors supplied IPD in a template format constructed a priori. Mean differences (MDs) between tests and pathology (i.e. systematic bias) were calculated and pooled by the inverse variance method; limits of agreement (LOA) were estimated. Test measurements of 0.0 cm in the presence of pathologic residual tumor, and measurements >0.0 cm despite pathologic complete response (pCR) were described for MRI and alternative tests. Results: Eight studies contributed IPD (N = 300). The pooled MD for MRI was 0.0 cm (LOA: +/-3.8 cm). Ultrasound underestimated pathologic size (MD: -0.3 cm) relative to MRI (MD: 0.1 cm), with comparable LOA. MDs were similar for MRI (0.1 cm) and mammography (0.0 cm), with wider LOA for mammography. Clinical examination underestimated size (MD: -0.8 cm) relative to MRI (MD: 0.0 cm), with wider LOA. Tumors "missed" by MRI typically measured 2.0 cm or less at pathology; tumors >2.0 cm were more commonly "missed" by clinical examination (9.3 %). MRI measurements >5.0 cm occurred in 5.3 % of patients with pCR, but were more frequent for mammography (46.2 %). Conclusions: There was no systematic bias in MRI tumor measurement, but LOA are large enough to be clinically important. MRI's performance was generally superior to ultrasound, mammography, and clinical examination, and it may be considered the most appropriate test in this setting. Test combinations should be explored in future studies.
BMC Cancer 12/2015; 15(1). DOI:10.1186/s12885-015-1664-4 · 3.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined interpretive efficiency and variability in true- and false-positive detection (TP, FP) for radiologists screen-reading with digital breast tomosynthesis as adjunct to full-field digital mammography (2D/3D) relative to 2D alone in population-based screening studies. A systematic literature search was performed to identify screening studies that provided radiologist-specific data for TP and FP detection. Radiologist interpretive efficiency (trade-off between TPs and FPs) was calculated using the FP:TP ratio which expresses the number of FP recalls for each screen-detected breast cancer. We modeled a pooled FP:TP ratio to assess variability in radiologists' interpretive efficiency at study-level using random effects logistic regression. FP:TP ratio improved (ratio decreased) for 2D/3D screen-reading (relative to 2D) for a majority of radiologists (18 of 22) across all studies. Variability in radiologists' FP:TP ratio was consistently lower in all studies for 2D/3D screen-reading, as suggested by lower variance in ratios. Study-level pooled FP:TP ratio for 2D- and 2D/3D-mammography respectively, were 5.96 (95%CI: 4.08 to 8.72) and 3.17 (95%CI: 2.25 to 4.47) for the STORM trial; 10.25 (95%CI: 6.42 to 16.35) and 7.07 (95%CI: 4.99 to 10.02) for the Oslo trial; and 20.84 (95%CI: 13.95 to 31.12) and 8.37 (95%CI: 5.87 to 11.93) for the Houston study. This transfers into study-level improved interpretative efficiencies of 48%, 30% and 55%, respectively, for 2D/3D screen-reading (relative to 2D). In summary, study-level FP:TP trade-off improved using 2D/3D-mammography for all studies, which was also seen for most individual radiologists. There was variability in the FP:TP trade-off between readers and studies for 2D-as well as for 2D/3D-interpretations but variability in radiologists' interpretive efficiency was relatively lower using 2D/3D-mammography.
The Breast 09/2015; DOI:10.1016/j.breast.2015.08.012 · 2.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Earlier detection of second breast cancers after primary breast cancer (PBC) treatment improves survival, yet mammography is less accurate in women with prior breast cancer. The purpose of this study was to examine women presenting clinically with second breast cancers after negative surveillance mammography (interval cancers), and to estimate the five-year risk of interval-invasive second cancers for women with varying risk profiles.
We evaluated a prospective cohort of 15 114 women with 47 717 surveillance mammograms diagnosed with stage 0-II unilateral PBC from 1996 through 2008 at facilities in the Breast Cancer Surveillance Consortium. We used discrete time survival models to estimate the association between odds of an interval-invasive second breast cancer and candidate predictors, including demographic, PBC, and imaging characteristics. All statistical tests were two-sided.
The cumulative incidence of second breast cancers after five years was 54.4 per 1000 women, with 325 surveillance-detected and 138 interval-invasive second breast cancers. The five-year risk of interval-invasive second cancer for women with referent category characteristics was 0.60%. For women with the most and least favorable profiles, the five-year risk ranged from 0.07% to 6.11%. Multivariable modeling identified grade II PBC (odds ratio [OR] = 1.95, 95% confidence interval [CI] = 1.15 to 3.31), treatment with lumpectomy without radiation (OR = 3.27, 95% CI = 1.91 to 5.62), interval PBC presentation (OR = 2.01, 95% CI 1.28 to 3.16), and heterogeneously dense breasts on mammography (OR = 1.54, 95% CI = 1.01 to 2.36) as independent predictors of interval-invasive second breast cancers.
PBC diagnosis and treatment characteristics contribute to variation in subsequent-interval second breast cancer risk. Consideration of these factors may be useful in developing tailored post-treatment imaging surveillance plans.
Journal of the National Cancer Institute 07/2015; 107(7). DOI:10.1093/jnci/djv109 · 12.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The evidence on digital breast tomosynthesis (DBT), or quasi-3D-mammography, for population breast screening has emerged rapidly: two prospective and several retrospective studies provide convincing evidence that mammography with DBT improves screening detection measures compared with standard mammography. Based on population screening studies (which have used various methodologies), adjunct DBT’s incremental breast cancer detection is in the range of 0.5–2.7/1000 screens, and the absolute false recall reduction attributed to DBT is in the range of 0.8–3.6%. Randomized controlled trials assessing the impact of DBT on interval cancer rates as a surrogate for screening benefit would provide critical evidence to underpin population screening policy and practice, and could be designed to also address existing evidence gaps including cost–effectiveness of DBT.
Expert Review of Medical Devices 05/2015; 12(4). DOI:10.1586/17434440.2015.1028362 · 1.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Preoperative breast magnetic resonance (MR) often generates additional suspicious findings needing further investigations. Targeted breast ultrasound (US) is the standard tool to characterize MR additional lesions. The purpose of this study is to evaluate the potential role of digital breast tomosynthesis (DBT) to characterize MR detected additional findings, unidentified at targeted breast US.
This prospective study included women who a) had biopsy-proven, newly diagnosed breast cancers detected at conventional 2D mammography and/or US, referred to breast MR for tumour staging; and b) had DBT if additional MR findings were not detected at targeted ('second look') US.
In 520 patients, MR identified 164 (in 114 women, 22 %) additional enhancing lesions. Targeted US identified 114/164 (69.5 %) of these, whereas 50/164 (30.5 %) remained unidentified. DBT identified 32/50 of these cases, increasing the overall characterization of MR detected additional findings to 89.0 % (146/164). Using DBT the identified lesions were significantly more likely to be malignant than benign MR-detected additional lesions (p = 0.04).
DBT improves the characterization of additional MR findings not identified at targeted breast US in preoperative breast cancer staging.
• Targeted US identified 114 of 164 (69.5 %) additional enhancing lesions at preoperative breast MRI. • DBT identified a further 32 of the 50 lesions unidentified on targeted US. • DBT improved the characterization of additional MR findings for breast cancer staging.
European Radiology 03/2015; 25(9). DOI:10.1007/s00330-015-3669-4 · 4.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Breast cancer places a heavy burden on the Australian healthcare system, but information about the actual number of women living with breast cancer and their current or future health service needs is limited. We used existing population-based data and innovative statistical methods to address this critical research question in a well-defined geographic region.
Breast cancer data from the New South Wales (NSW) Central Cancer Registry and PIAMOD (Prevalence and Incidence Analysis MODel) software were used to project future breast cancer prevalence in NSW. Parametric models were fitted to incidence and survival data, and the modelled incidence and survival estimates were then used to estimate current and future prevalence. To estimate future healthcare requirements the projected prevalence was then divided into phases of care according to the different stages of the survivorship trajectory.
The number of women in NSW living with a breast cancer diagnosis had increased from 19,305 in 1990 to 48,754 in 2007. This number is projected to increase further to 68,620 by 2017. The majority of these breast cancer survivors will require continued monitoring (31,974) or will be long-term survivors (29,785). About 9% will require active treatment (either initial therapy, or treatment for subsequent metastases or second cancer) and 1% will need end of life care due to breast cancer.
Extrapolating these projections to the national Australian population would equate to 209,200 women living with breast cancer in Australia in 2017, many of whom will require active treatment or post-treatment monitoring. Thus, careful planning and development of a healthcare system able to respond to this increased demand is required.
BMC Cancer 12/2014; 2014, 14:936(1):936. DOI:10.1186/1471-2407-14-936 · 3.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective To develop, pilot and refine a decision aid (ahead of a randomised trial evaluation) for women around age 50 facing their initial decision about whether to undergo mammography screening.
Design Two-stage mixed-method pilot study including qualitative interviews (n=15) and a randomised comparison using a quantitative survey (n=34).
Setting New South Wales, Australia.
Participants Women aged 43–59 years with no personal history of breast cancer.
Interventions The decision aid provides evidence-based information about important outcomes of mammography screening over 20 years (breast cancer mortality reduction, overdetection and false positives) compared with no screening. The information is presented in a short booklet for women, combining text and visual formats. A control version produced for the purposes of comparison omits the overdetection-related content.
Outcomes Comprehension of key decision aid content and acceptability of the materials.
Results Most women considered the decision aid clear and helpful and would recommend it to others. Nonetheless, the piloting process raised important issues that we tried to address in iterative revisions. Some participants found it hard to understand overdetection and why it is of concern, while there was often confusion about the distinction between overdetection and false positives. In a screening context, encountering balanced information rather than persuasion appears to be contrary to people's expectations, but women appreciated the opportunity to become better informed.
Conclusions The concept of overdetection is complex and new to the public. This study highlights some key challenges for communicating about this issue. It is important to clarify that overdetection differs from false positives in terms of its more serious consequences (overtreatment and associated harms). Screening decision aids also must clearly explain their purpose of facilitating informed choice. A staged approach to development and piloting of decision aids is recommended to further improve understanding of overdetection and support informed decision-making about screening.
BMJ Open 09/2014; 4(9):e006016. DOI:10.1136/bmjopen-2014-006016 · 2.27 Impact Factor