Article

Association of Digital Breast Tomosynthesis vs Digital Mammography With Cancer Detection and Recall Rates by Age and Breast Density

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Abstract

Importance Breast cancer screening examinations using digital breast tomosynthesis (DBT) has been shown to be associated with decreased false-positive test results and increased breast cancer detection compared with digital mammography (DM). Little is known regarding the size and stage of breast cancer types detected and their association with age and breast density. Objective To determine whether screening examinations using DBT detect breast cancers that are associated with an improved prognosis and to compare the detection rates by patient age and breast density. Design, Setting, and Participants This retrospective analysis of prospective cohort data from 3 research centers in the Population-based Research Optimizing Screening Through Personalized Regimens (PROSPR) consortium included data of women aged 40 to 74 years who underwent screening examinations using DM and DBT from January 1, 2011, through September 30, 2014. Statistical analysis was performed from November 8, 2017, to August 14, 2018. Exposures Use of DBT as a supplement to DM at breast cancer screening examination. Main Outcomes and Measures Recall rate, cancer detection rate, positive predictive value, biopsy rate, and distribution of invasive cancer subtypes. Results Among 96 269 women (mean [SD] patient age for all examinations, 55.9 [9.0] years), patient age was 56.4 (9.0) years for DM and 54.6 (8.9) years for DBT. Of 180 340 breast cancer screening examinations, 129 369 examinations (71.7%) used DM and 50 971 examinations (28.3%) used DBT. Screening examination with DBT (73 of 99 women [73.7%]) was associated with the detection of smaller, more often node-negative, HER2–negative, invasive cancers compared with DM (276 of 422 women [65.4%]). Screening examination with DBT was also associated with lower recall (odds ratio, 0.64; 95% CI, 0.57-0.72; P < .001) and higher cancer detection (odds ratio, 1.41; 95% CI, 1.05-1.89; P = .02) compared with DM for all age groups even when stratified by breast density. The largest increase in cancer detection rate and the greatest shift toward smaller, node-negative invasive cancers detected with DBT was for women aged 40 to 49 years. For women aged 40 to 49 years with nondense breasts, the cancer detection rate for examinations using DBT was 1.70 per 1000 women higher compared with the rate using DM; for women with dense breasts, the cancer detection rate was 2.27 per 1000 women higher for DBT. For these younger women, screening with DBT was associated with only 7 of 28 breast cancers (25.0%) categorized as poor prognosis compared with 19 of 47 breast cancers (40.4%) when screening with DM. Conclusions and Relevance The findings suggest that screening with DBT is associated with increased specificity and an increased proportion of breast cancers detected with better prognosis compared with DM. In the subgroup of women aged 40 to 49 years, routine DBT screening may have a favorable risk-benefit ratio.

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... 1,2 Several observational studies have demonstrated that women screened with DBT are less likely to be called back for additional diagnostic imaging compared to women screened with 2-D mammography, a measure known as recall. [3][4][5][6][7] Other studies have shown higher cancer detection rates when DBT is used over 2-D mammography. [8][9][10][11][12][13] Some studies have examined screening outcomes using DBT compared to 2-D mammography specifically among older women. ...
... Our findings differ from several studies which have shown that DBT is associated with lower recall rates compared to 2-D screening mammography. 5,6,8 Lower recall has been held up as a major advantage of DBT, as further workup creates additional anxiety and expense. We have shown that DBT is not associated with use of less subsequent imaging among older women, suggesting that this potential advantage has not been realized in this group. ...
... The performance of 2-D mammography itself improves with age and some studies have suggested a larger absolute reduction in recall with DBT among younger women compared to older women. 25,5,15 However, not all studies have shown consistent age effects, and there are important remaining questions about how age, breast density, and screening round may all impact DBT performance among older women. 26 Consistent with prior studies, we observed that DBT was associated with higher rates of cancer detection compared to 2-D mammography. ...
Article
Background Digital breast tomosynthesis (DBT) has become a prevalent mode of breast cancer screening in recent years. Although older women are commonly screened for breast cancer, little is known about screening outcomes using DBT among older women.Objective To assess proximal screening outcomes with DBT compared to traditional two-dimensional(2-D) mammography among women 67–74 and women 75 and older.DesignCohort study.ParticipantsMedicare fee-for-service beneficiaries aged 67 years and older with no history of prior cancer who received a screening mammogram in 2015.Main MeasuresUse of subsequent imaging (ultrasound and diagnostic mammography) as an indication of recall, breast cancer detection, and characteristics of breast cancer at the time of diagnosis. Analyses used weighted logistic regression to adjust for potential confounders.Key ResultsOur study included 26,406 women aged 67–74 and 17,001 women 75 and older who were screened for breast cancer. Among women 75 and older, the rate of subsequent imaging among women screened with DBT did not differ significantly from 2-D mammography (91.8 versus 97.0 per 1,000 screening mammograms, p=0.37). In this age group, DBT was associated with 2.1 additional cancers detected per 1,000 screening mammograms compared to 2D (11.5 versus 9.4, p=0.003), though these additional cancers were almost exclusively in situ and stage I invasive cancers. For women 67–74 years old, DBT was associated with a higher rate of subsequent imaging than 2-D mammography (113.9 versus 100.3, p=0.004) and a higher rate of stage I invasive cancer detection (4.7 versus 3.7, p=0.002), but not other stages.Conclusions Breast cancer screening with DBT was not associated with lower rates of subsequent imaging among older women. Most additional cancers detected with DBT were early stage. Whether detecting these additional early-stage cancers among older women improves health outcomes remains uncertain.
... For the DBT arm, a total of 489 different studies were found eligible for abstract screening, 33 studies were checked at full-text ( Figure 1). Seventeen studies [10,[34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] met our inclusion criteria for synthesis and meta-analysis. Additionally, for the CBBCT, 836 different studies were eligible for the title and abstract screening, nine were assessed for full text, and finally, only five studies met our predefined condition [11][12][13]48,49]. ...
... For the DBT arm, with 17 studies included, which comprise of retrospective screening studies [34,40,42,[44][45][46][48][49][50][51] and prospective studies [35][36][37][38], few prospective clinical trials [10,39], above 95% of all included studies are comparative. All the studies reported sensitivity and specificity, in which the (2 × 2) confusion matrix can be derived, other parameters like positive and negative likelihood ratios and AUC of SROC were estimated using MetaDiSc [31] and "mada" package of R, respectively [30]. ...
... Most of the studies specified the total number of benign and malignant lesion cases [10,35,37,38,[41][42][43][44][45][46][47]. Approximately 53 % of the studies data were acquired using the Hologic Selenium Dimension model [10,34,36,40,[44][45][46][47], 13% goes for Siemens Mammomat Inspiration model [38,39], and 13% also for GE Senographe Essential model [37,42]. ...
Article
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Background: Cone-beam breast computed tomography (CBBCT) and digital breast tomosynthesis (DBT) remain the main 3D modalities for X-ray breast imaging. This study aimed to systematically evaluate and meta-analyze the comparison of diagnostic accuracy of CBBCT and DBT to characterize breast cancers. Methods: Two independent reviewers identified screening on diagnostic studies from 1 January 2015 to 30 December 2021, with at least reported sensitivity and specificity for both CBBCT and DBT. A univariate pooled meta-analysis was performed using the random-effects model to estimate the sensitivity and specificity while other diagnostic parameters like the area under the ROC curve (AUC), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were estimated using the bivariate model. Results: The pooled sensitivity specificity, LR+ and LR- and AUC at 95% confidence interval are 86.7% (80.3-91.2), 87.0% (79.9-91.8), 6.28 (4.40-8.96), 0.17 (0.12-0.25) and 0.925 for the 17 included studies in DBT arm, respectively, while, 83.7% (54.6-95.7), 71.3% (47.5-87.2), 2.71 (1.39-5.29), 0.20 (0.04-1.05), and 0.831 are the pooled sensitivity specificity, LR+ and LR- and AUC for the five studies in the CBBCT arm, respectively. Conclusions: Our study demonstrates that DBT shows improved diagnostic performance over CBBCT regarding all estimated diagnostic parameters; with the statistical improvement in the AUC of DBT over CBBCT. The CBBCT might be a useful modality for breast cancer detection, thus we recommend more prospective studies on CBBCT application.
... Although these studies have consistently shown an increase in detection of cancer, particularly invasive cancer, the majority of data are from first-round screening only, and questions of overestimation and sustainability of the advantage of cancer detection with DBT have been raised. Emerging longitudinal data from prospective studies (2,23) are shedding light on longer-term use, but results are mixed. Although studies (8,(24)(25)(26) have shown a continued benefit from the use of DBT over consecutive rounds of screening, the extent of this gain varies, and the expected increase in cancer detection is not significant in some studies. ...
... and the other (27) showed cancer detection rates of 5.24 versus 4.6 per 1000 examinations, respectively (P = .37). Nevertheless, sustained preferential detection of invasive cancers is demonstrated in most studies across age groups and breast density categories (23,27). Women who underwent their first DBT examination had a higher yield of cancer than did those who underwent at least one prior DBT examination (6.1 vs 4.4-5.7 per 1000 examinations, respectively) (P < .05) ...
... respectively; P < .001), and less likely to be node positive (11.2% vs 19.0%) (23,24,28,34). Cancers detected only with DBT, in particular, are more likely to be grade 1 tumors (DBT-only vs all cancers, respectively, 41.7% vs 12.1%; P < .001), of the luminal A-like subtype (45.8% vs 13.5%, respectively; P < .001), ...
Article
Digital breast tomosynthesis (DBT) has been widely adopted in breast imaging in both screening and diagnostic settings. The benefits of DBT are well established. Compared with two-dimensional digital mammography (DM), DBT preferentially increases detection of invasive cancers without increased detection of in-situ cancers, maximizing identification of biologically significant disease, while mitigating overdiagnosis. The higher sensitivity of DBT for architectural distortion allows increased diagnosis of invasive cancers overall and particularly improves the visibility of invasive lobular cancers. Implementation of DBT has decreased the number of recalls for false-positive findings at screening, contributing to improved specificity at diagnostic evaluation. Integration of DBT in diagnostic examinations has also resulted in an increased percentage of biopsies with positive results, improving diagnostic confidence. Although individual DBT examinations have a longer interpretation time compared with that for DM, DBT has streamlined the diagnostic workflow and minimized the need for short-term follow-up examinations, redistributing much-needed time resources to screening. Yet DBT has limitations. Although improvements in cancer detection and recall rates are seen for patients in a large spectrum of age groups and breast density categories, these benefits are minimal in women with extremely dense breast tissue, and the extent of these benefits may vary by practice environment and by geographic location. Although DBT allows detection of more invasive cancers than does DM, its incremental yield is lower than that of US and MRI. Current understanding of the biologic profile of DBT-detected cancers is limited. Whether DBT improves breast cancer-specific mortality remains a key question that requires further investigation. ©RSNA, 2021.
... DBT generates a quasi-three-dimensional mammogram by obtaining multiple low-dose exposures across a limited arc, which are then reconstructed into a series of images or "slices" of the breast. Population-based studies from both the United States and Europe have demonstrated initial and sustained reductions in recall rates (RR) and/or increases in invasive cancer detection rates (CDRs) with DBT plus DM (referred to as DBT throughout) compared with DM screening alone [7][8][9][10]. ...
... Improvements are consistent with those seen in other studies that analyzed performance in aggregate but did not report results by racial group. [7][8][9] Studies that quantify racial disparities are instrumental to the identification and 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 implementation of customized solutions to improve breast cancer outcomes in select populations. ...
... This study demonstrated that more frequent screening was associated with lower RR, for both DBT and DM, as has been described previously [7][8][9][10]. Although the observed overall RR was within the ACR's recommended range of 5% to 12% [20], RR varied widely by subpopulation, from a low of 6.70% in black women with at least two screenings and screened with DBT to a maximum of 20.98% in Asian women screened once with DM. ...
Article
Full-text available
Purpose Digital breast tomosynthesis (DBT) in conjunction with digital mammography (DM) is becoming the preferred imaging modality for breast cancer screening compared with DM alone, on the basis of improved recall rates (RR) and cancer detection rates (CDRs). The aim of this study was to investigate racial differences in the utilization and performance of screening modality. Methods Retrospective data from 63 US breast imaging facilities from 2015 to 2019 were reviewed. Screening outcomes were linked to cancer registries. RR, CDR per 1,000 examinations, and positive predictive value for recall (cancers/recalled patients) were compared. Results A total of 385,503 women contributed 542,945 DBT and 261,359 DM screens. A lower proportion of screenings for black women were performed using DBT plus DM (referred to as DBT) (44% for black, 48% for other, 63% for Asian, and 61% for Caucasian). Non-Caucasian women were less likely to undergo more than one mammographic examination. RRs were lower for DBT among all women (8.74 vs 10.06, P < .05) and lower across all races and within age categories. RRs were significantly higher for women with only one mammogram. CDRs were similar or higher in women undergoing DBT compared with DM, overall (4.73 vs 4.60, adjusted P = .0005) and by age and race. Positive predictive value for recall was greater for DBT overall (5.29 vs 4.45, adjusted P < .0001) and by age, race, and screening frequency. Conclusions All racial groups had improved outcomes with DBT screening, but disparities were observed in DBT utilization. These data suggest that reducing inequities in DBT utilization may improve the effectiveness of breast cancer screening.
... Our results were comparable to prior studies done by Conant et al. [11], Skaane et al. [12], and Divya et al. [13] who reported increased sensitivity, specificity, and increased cancer detection when DBT was used. Skaane et al. found increase sensitivity from 54.1 to 70.5% and mild increase in specificity from 94 to 95% by using DBT compared to digital mammography [12]. ...
... Our results supported by the literature of Conant et al. [11] in their study about digital breast tomosynthesis vs digital mammography in cancer detection and recall rates in different ages and breast densities. He concluded that screening with DBT simultaneously improved breast cancer detection while reducing falsepositive recalls which were significant across all age groups and breast densities categories. ...
Article
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Background Mammography has been the mainstay for the detection of breast cancer over decades. It has gradually advanced from screen film to full-field digital mammography. Tomosynthesis has evolved as advanced imaging for early diagnosis of breast lesions with a promising role in both diagnostic and screening settings, particularly in dense and treated breasts. Results This study included 90 female patients according to our inclusion criteria. All patients perform full-field digital mammography (FFDM) and digital breast tomosynthesis (DBT) and were classified according to breast density and age groups. Breast imaging reporting and data system (BI-RADS) scoring was assigned for each case. This was correlated with the final diagnosis; the diagnostic indices of mammography were a sensitivity of 64.44%, a specificity of 77.78%, a positive predictive value (PPV) 74.63%, a negative predictive value (NPV) of 68.63%, and a diagnostic accuracy of 71.11%. Diagnostic indices of DBT were a sensitivity of 100%, a specificity of 97.77%, PPV 97.78%, NPV 100%, and diagnostic accuracy of 97.7%. In patients with dense breasts American College of Radiology (ACR) (c and d), 61% of cases had changed their BIRADS scoring with the addition of tomosynthesis. Yet, in non-dense breast ACR (a and b), 45% of cases had changed BIRADS scoring with the addition of DBT to FFDM. Conclusion DBT is a promising imaging modality offering better detection and characterization of different breast abnormalities, especially in young females, and those with dense breasts with an increase of sensitivity and specificity than FFDM. This leads to a reduction in the recalled cases, negative biopsies, and assessing the efficacy of therapy as it enables improving detection of breast cancer and different breast lesions not visualized by conventional mammography
... In most of the developing regions, the incidence rates are under 40 per 100,000 (Ferlay, et al., 2019). Breast cancer survival rates vary greatly worldwide, ranging from 80% or more in North America, Sweden and Japan to around 60% in middle-income countries and below 40% in low-income countries (Conant, et al., 2019). The low survival rates in low-income countries can be clarified mainly by inadequate early detection programs, resulting in a high proportion of women presenting with late-stage disease, as well as by the lack of adequate diagnosis and treatment amenities (Conant, et al., 2019). ...
... Breast cancer survival rates vary greatly worldwide, ranging from 80% or more in North America, Sweden and Japan to around 60% in middle-income countries and below 40% in low-income countries (Conant, et al., 2019). The low survival rates in low-income countries can be clarified mainly by inadequate early detection programs, resulting in a high proportion of women presenting with late-stage disease, as well as by the lack of adequate diagnosis and treatment amenities (Conant, et al., 2019). ...
Article
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The study examined the prevalence of breast cancer among cancer patients attending cancer clinic at Federal Teaching Hospital, Ido-Ekiti, Ekiti State. Specifically, the study examined the prevalence of and the most common types of breast cancer among patients attending cancer clinic, Federal Teaching Hospital Ido-Ekiti, Ekiti State. This study was a ten (10) years retrospective, descriptive study of consecutive female adult with diagnosis of breast cancer attending cancer clinic. The facility was purposively selected being the only Federal Teaching Hospital in Ekiti State where national cancer registry is located. This study was a 10-year retrospective study and the data extracted from the patient's case note and clinic register includes age, religion, ethnicity, occupation, gravid, parity, number of children, date of admission, date of discharge and stages of breast cancer. Descriptive statistics of frequency, percentage, mean and standard deviation where applicable and inferential statistics of Pearson correlation was used for testing both hypotheses at 0.05 level of significance. The findings of the study revealed high prevalence of breast cancer among other categories of cancer. In addition, the most occurring stage of breast cancer was stage 2. The study also revealed that socio-demographic characteristics influence prevalence of breast cancer while reproductive history was related to prevalence of breast cancer. It was recommended among others that Nurses should health educate all the women of childbearing age on how to do self-breast examination, because it enhances early detection of breast cancer. IJARBAS
... There is currently little data on interval cancers by density for digital breast tomosynthesis (DBT), but it is unlikely that tomosynthesis is going to overcome the reduction in sensitivity caused by density. Several studies reported increased cancer detection rates by 20 to 40% also in women with (extremely) dense breasts [22,23], mainly due to the detection of more spiculated masses and architectural distortions, but there is only limited evidence that this leads to reduced rates of interval cancers in these women. According to Conant et al, the sensitivity of DM and DBT was similarly based upon 1-year follow-up [23]. ...
... Several studies reported increased cancer detection rates by 20 to 40% also in women with (extremely) dense breasts [22,23], mainly due to the detection of more spiculated masses and architectural distortions, but there is only limited evidence that this leads to reduced rates of interval cancers in these women. According to Conant et al, the sensitivity of DM and DBT was similarly based upon 1-year follow-up [23]. X-ray-based anatomic imaging modalities-being either screen-film mammography, FFDM or DBT-all seem to be heavily affected by breast density and thus lead to underdiagnosis of relevant cancers in these women. ...
Article
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Breast density is an independent risk factor for the development of breast cancer and also decreases the sensitivity of mammography for screening. Consequently, women with extremely dense breasts face an increased risk of late diagnosis of breast cancer. These women are, therefore, underserved with current mammographic screening programs. The results of recent studies reporting on contrast-enhanced breast MRI as a screening method in women with extremely dense breasts provide compelling evidence that this approach can enable an important reduction in breast cancer mortality for these women and is cost-effective. Because there is now a valid option to improve breast cancer screening, the European Society of Breast Imaging (EUSOBI) recommends that women should be informed about their breast density. EUSOBI thus calls on all providers of mammography screening to share density information with the women being screened. In light of the available evidence, in women aged 50 to 70 years with extremely dense breasts, the EUSOBI now recommends offering screening breast MRI every 2 to 4 years. The EUSOBI acknowledges that it may currently not be possible to offer breast MRI immediately and everywhere and underscores that quality assurance procedures need to be established, but urges radiological societies and policymakers to act on this now. Since the wishes and values of individual women differ, in screening the principles of shared decision-making should be embraced. In particular, women should be counselled on the benefits and risks of mammography and MRI-based screening, so that they are capable of making an informed choice about their preferred screening method. Key Points • The recommendations in Figure 1 summarize the key points of the manuscript
... Studies show that how DBT [17][18][19] and AI-CAD [13,16,20]improve the performance characteristics of mammography , but few have evaluated how these additional modalities perform when used to interpret the mammography of women with a personal history of breast cancer that are under surveillance after BCT. ...
Article
This study [1] characterizes the longitudinal and cross-sectional associations between lumbar radiographic findings and back pain-related disability (BPRD) in the Chingford 1000 Women Study, a population-based longitudinal cohort. One rheumatologist classified the degree of disc space narrowing (DSN), endplate sclerosis or deformity, and osteophytes by combining the number of vertebral bodies involved and type of osteoarthritic changes using the Kellgren-Lawrence grading (KLG) system and a previously described semiquantitative method. The researchers generated separate composite scores for KLG, DSN, and osteophyte grade. The data were derived from different study stages including year 6 physical activity score; year 9 imaging, other covariates, and cross-sectional outcomes; and year 15 longitudinal outcomes. The primary outcome was self-reported back pain of at least one day in the last 12 months from the St. Thomas disability questionnaire. Covariates included age, body mass index, smoking, back pain, bisphosphonate usage, and self-reported physical activity. A total of 650 women and 443 women met inclusion criteria for the cross-sectional and longitudinal analyses, respectively. Median BPRD was zero; approximately two thirds of participants reported no BPRD. No lumbar spine radiographic findings were found in 154/650 women. Of the women with one or more KLG composite changes, osteophyte composite changes, or DSN composite changes, no association was found with BPRD in either analysis. In summary, in this cohort, no association was found between the number of segments with radiographic changes (KLG composite, osteophyte composite, DSN composite) and more severe BPRD.
... Digital mammograms have been found to show up to 89.3% diagnostic accuracy at detecting breast cancer cases [23], but none of the various standard techniques used for breast imaging are 100% effective, especially for tiny tumors, diffusely infiltrating carcinomas like invasive lobular cancers, and ductal in-situ cancers without microcalcifications [24,25]. With advances in technology, digital breast tomosynthesis (DBT) compared to digital mammography (2D) has been touted to improve cancer detection rates and avoid unnecessary biopsies, despite its slightly higher radiation dose [26][27][28]. While a lot of hospitals and health systems have transitioned fully to systemwide use of the DBT modality for all mammography examinations, several scientific questions remain unanswered. ...
Article
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Purpose Probability of malignancy for BI-RADS 4-designated breast lesions ranges from 2-95%, contributing to high false-positive biopsy rates. We compare clinical performance of digital breast tomosynthesis (DBT) versus digital mammography (2D) among our BI-RADS 4 population without prior history of breast cancer. Methods We extracted retrospective data i.e., clinical, mammogram reports, and biopsy data, from electronic medical records across our institution’s nine hospitals for patients who underwent diagnostic examinations using both modalities (02/01/2015 – 09/30/2020). 2D and DBT cohorts were not intra-individual matched, and there was no direct mammogram evaluation. Using Student’s t test, Fisher's exact test, and Chi-squared test, we evaluated the data to determine statistical significance of differences between modalities in BI-RADS 4 cases. We calculated adjusted odds-ratio between modalities for cancer detection rate (CDR) and biopsy-derived positive predictive value (PPV3). Results There were 6,356 encounters (6,020 patients) in 2D and 5,896 encounters (5,637 patients) in DBT assessed as BI-RADS 4. Using Fisher’s exact test, DBT mammography cases were significantly assessed as BI-RADS 4 5.66% more often than those undergoing 2D mammography, P=0.0046 (1.0566 95% CI: 1.0169 - 1.0977). The CDRs were 112.65 (2D) and 120.76 (DBT), adjusted odds-ratio: 1.04 (0.93, 1.16)), P=0.5029, while PPV3 were 14.41% (2D) and 15.99% (DBT), adjusted odds-ratio: 1.09 (0.97, 1.22), P=0.1483; both logistic regression-adjusted for all other factors. Conclusion DBT did not achieve better performance and sensitivity in assigning BI-RADS 4 cases compared with 2D, showed no significant advantage in CDR and PPV3, and does not reduce false-positive biopsies among BI-RADS 4-assessed patients.
... A representative case of breast density impacting the interpretation of mammogram is illustrated in Fig. 1. The impact of breast density extends from increased false-positive findings [40,41] and reduction in cancer detection [42] to higher interval cancer rates [43,44]. In addition, breast density results in increased risk of higher stage cancers [34,45] which can minimize the mortality reduction [46] benefit of mammographic screening. ...
Article
Purpose: To present details about the innovative and disruptive technology of monochromatic X-rays and its application to breast imaging. Methods: To analyze results of studies done using a prototype system for breast imaging that generates monochromatic X-rays through fluorescence emission. To assess signal-to-noise ratio (SNR) as a measure of image quality at different doses in breast phantoms of different sizes and review the comparison of parameters with a standard mammography system. Results: Monochromatic X-rays reduce the radiation dose per mammogram by a factor of 5 to 10 times. For phantom simulating thick breast (9 cm), the SNR for monochromatic system was 2.6 times higher and the dose 4.2 times lower than the respective values obtained with the conventional system within the same 5 mm × 5 mm square area of the 100% glandular step wedge. For the conventional broadband system to equal the SNR of the monochromatic system, it would require a dose of 19 mGy, 29 times higher than the dose delivered by the monochromatic system. Contrast-enhanced digital mammography with monochromatic X-rays is shown to provide a simpler and more effective technique at substantially lower radiation dose. Conclusions: Lowering radiation dose by a factor of 5 to 10 while maintaining image quality implies a major reduction in total exposure from breast cancer screening and dramatically less risk of radiation-induced cancers in at-risk women. The high SNRs for very thick breast phantoms provide strong evidence that screening with lower breast compression is possible while maintaining image quality.
... In women with dense breast tissue, the percentage of missed cancers is even higher [4][5][6]. The results of several successive retrospective and prospective screening studies reveal the potential of tomosynthesis in BC screening [7][8][9][10][11]. Also, the combination of tomosynthesis and mammography can reduce the number of false-positive screening results and increase the BC detection rate compared to mammography alone [12]. ...
Article
Relevance: Breast cancer is the most common malignant neoplasm among wom-en in our country. Mammography is currently the method of choice in breast can-cer diagnostics. However, it has limitations associated with the imposition of breast tissue layers, which makes it difficult to identify lesions and leads to a mis-diagnosis. Breast tomosynthesis is a tomographic technique in which the effect of tissue superimposition is significantly reduced due to layer-by-layer scanning. The purpose of this study was to review the capacity of tomosynthesis in the di-agnosis of breast cancer. Results: The combination of tomosynthesis with a synthesized image is the best technology for screening because it offers the best combination of efficiency and radiation dose. Advantages include greater diagnostic accuracy due to both in-creased sensitivity and specificity, and a significantly less need for additional mammography projections (targeted mammography, targeted mammography with magnification). Conclusions: Tomosynthesis as a diagnostic method significantly exceeds the method of mammography. The higher informative value of the results provided by tomosynthesis reduces the frequency of false-negative and false-positive radio-logical conclusions.
... 16 Compared with FM, the size of cancer detected by DBT is smaller, and the rate of negative lymph node invasion is higher. 17 A recent meta-analysis including 17 studies (1,009,790 participants) demonstrated an incremental cancer detection rate of 1.6/1000 screenings (95% confidence interval [CI]: 1.1-2.0, p < 0.001) and an absolute reduction in recall rate of 2.2% (95% CI: 3.0-1.4, ...
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Breast cancer (BC) is the most prevalent malignancy worldwide, and a continued upward trend has been predicted in the coming decades. Screening in selected targeted populations, which is effective in reducing cancer‐related mortality, has been widely implemented in many countries. This review summarizes the advances in BC screening techniques, organized or opportunistic BC screening programs across different countries, and screening modalities recommended by different academic authorities. Mammography is the most widely used and effective technique for BC screening. Other complementary techniques include ultrasound, clinical breast examination, and magnetic resonance imaging. Novel screening tests, including digital breast tomosynthesis and liquid biopsies, are still under development. Globally, the implementation status of BC screening programs is uneven, which is reflected by differences in screening modes, techniques, and population coverage. The recommended optimal screening strategies varied according to the authoritative guidelines. The effectiveness of current screening programs is influenced by several factors, including low detection rate, high false‐positive rate, and unsatisfactory coverage and uptake rates. Exploration of accurate BC risk prediction models and the development of risk‐stratified screening strategies are highly warranted in future research. Mammography is the most widely used and most effective technique; other complementary techniques include ultrasound, clinical breast examination, and magnetic resonance imaging. Globally, the implementation status of breast cancer screening programs is uneven, which is reflected by differences in screening modes, techniques, and examination coverage. Combining effective risk prediction models and advanced screening techniques for risk‐stratified screening strategies may be the future direction.
... An early population-based study in the US suggests that DBT plus DM will be able to replicate observational findings. 32 Definitive outcomes from the ongoing randomized Tomosynthesis Mammographic Imaging Screening Trial (NCT02616432) will, however, clarify the diagnostic accuracy of DBT screening and its ability to improve the stage distribution of screen-detected breast cancer. Central to these results will be the ability of DBT plus DM to reduce interval cancer rates, which are more likely to be diagnosed as high-risk breast cancer. ...
Article
Background: Observational studies show that digital breast tomosynthesis (DBT) combined with digital mammography (DM) can reduce recall rates and increases rates of breast cancer detection. The objective of this study was to examine the cost-effectiveness of DBT plus DM versus DM alone in British Columbia and to identify parameters that can improve the efficiency of breast cancer screening programs. Methods: We conducted an economic analysis based on data from a cohort of screening participants in the BC Cancer Breast Screening Program. The decision model simulated lifetime costs and outcomes for participants in breast cancer screening who were aged 40-74 years between 2012 and 2017. We analyzed rates of health care resource utilization, health state costs and estimated incremental cost-effectiveness ratios (ICERs), to measure incremental cost differences per quality-adjusted life years (QALYs) gained from the addition of DBT to DM-based screening, from the government payer's perspective. Results: The model simulated economic outcomes for 112 249 screening participants. We found that the ICER was highly sensitive to recall rate reductions and insensitive to parameters related to cancer detection. If DBT plus DM can reduce absolute recall rates by more than 2.1%, the base-case scenario had an ICER of $17 149 per QALY. At a willingness-to-pay threshold of $100 000 per QALY, more than 95% of the probabilistic simulations favoured the adoption of DBT plus DM versus DM alone. The ICER depended heavily on the ability of DBT plus DM to reduce recall rates. Interpretation: The addition of DBT to DM would be considered cost-effective owing to the low positive predictive value of screening with DM alone. Reductions in false-positive recall rates should be monitored closely.
... D igital breast tomosynthesis (DBT) has been shown to have higher sensitivity in screening than digital mammography (DM) (1)(2)(3)(4)(5). The additional invasive cancers detected at DBT seem to have similar or more favorable tumor characteristics than cancers detected at DM, such as higher proportions of small, spiculated, low-grade, luminal A-like tumors (4,(6)(7)(8). To determine whether the additional cancers detected at DBT constitute a potential screening benefit and do not simply contribute to overdiagnosis, interval cancer rates in DBT screening should be compared with those in DM screening (9). ...
Article
Background: Interval cancer rates can be used to evaluate whether screening with digital breast tomosynthesis (DBT) contributes to a screening benefit. Purpose: To compare interval cancer rates and tumor characteristics in DBT screening to those in a contemporary population screened with digital mammography (DM). Materials and Methods: The prospective population-based Malmö Breast Tomosynthesis Screening Trial (MBTST) was designed to compare one-view DBT to two-view DM in breast cancer detection. The interval cancer rates and cancer characteristics in the MBTST were compared with an age-matched contemporary control group, screened with two-view DM at the same center. Conditional logistic regression was used for data analysis. Results: There were 14 848 women who were screened with DBT and DM in the MBTST between January 2010 and February 2015. The trial women were matched with two women of the same age and screening occasion at DM screening during the same period. Matches for 13 369 trial women (mean age, 56 years ± 10 [standard deviation]) were found with 26 738 women in the control group (mean age, 56 years ± 10). The interval cancer rate in the MBTST was 1.6 per 1000 screened women (21 of 13 369; 95% CI: 1.0, 2.4) compared with 2.8 per 1000 screened women in the control group (76 of 26 738 [95% CI: 2.2, 3.6]; conditional odds ratio, 0.6 [95% CI: 0.3, 0.9]; P = .02). The invasive interval cancers in the MBTST and in the control group showed in general high Ki-67 (63% [12 of 19] and 75% [54 of 72]), and low proportions of luminal A–like subtype (26% [five of 19] and 17% [12 of 72]), respectively. Conclusion: The reduced interval cancer rate after screening with digital breast tomosynthesis compared with a contemporary age-matched control group screened with digital mammography might translate into screening benefits. Interval cancers in the trial generally had nonfavorable characteristics.
... Recent studies have mostly included BI-RADS category 0 patients and found DBT to be superior to US (15,17). In the present study, indeterminate lesions (BI-RADS 0, 3, and 4) were investigated. ...
Article
Background: Digital mammography (DM) is one of the most common and effective radiological methods for breast cancer screening and detection. A dense fibroglandular breast tissue can lead to false negative results by superimposing on the lesion margins. Therefore, adjunctive imaging methods, such as digital breast tomosynthesis (DBT) and ultrasonography (US), are needed to increase mammographic sensitivity. Objectives: This study aimed to examine the contribution of US and DBT to DM in different patient groups (patients group of BI-RADS 0 and 3-4 lesions, patients with dense breast parenchyma, patients with non-dense breast parenchyma).. Whether US and DBT can upgrade or downgrade the BI-RADS category of uncertain lesions detected on DM was also investigated. Patients and Methods: Forty-six patients, who were classified as BI-RADS categories 0, 3, and 4 in DM, according to DBT and US findings, were included in the study. DM followed by DBT was performed for the patients, and the BI-RADS classification system was applied. Subsequently, the patients were evaluated sonographically, and the BI-RADS system was applied according to the US results. Each BI-RADS category was compared with the histopathological and multimodality follow-up results. The diagnostic performance of all modalities was also examined alone and in combination. Results: The sensitivity and specificity of DM alone was 42% and 87%, respectively. DBT detected the lesions with 92% sensitivity and 68% specificity. The modality with the highest sensitivity for the detection of malignant lesions was US (100%). Besides, the specificity of DBT was significantly high for dense breasts (P < 0.001). There was no significant difference in terms of the diagnostic accuracy of US measurements between dense and non-dense breasts. For indeterminate lesions, the integration of DBT and US to DM increased the diagnostic accuracy. Conclusion: The contribution of DBT is more valuable than US in patients with dense breast parenchyma.
... Studie mit primärer Tomosynthese bei dichter Brust mit ansteigenden Altersgruppen von 40-49 Jahren, 50-64 Jahren und 65-74 Jahren Detektionsraten von 5,2 bzw. 7,6 und 9,6 pro 1000 untersuchte Frauen berichtet[39].Die Vorteile der hohen Karzinomdetektionsrate und niedrigen Intervallkarzinomrate (DENSE-Studie) müssen nachteiligen Effekten wie hohen falschpositiven Biopsieraten sowie vermehrten Kontrollen gegenübergestellt werden.Würden bei 10 Runden pro Runde 5-7 % Biopsien und weitere ca.8 % kurzfristige Kontrollen anfallen, würden 50-70 % dieser gescreenten Frauen nach 10 Runden mindestens eine Biopsie erlebt haben und weitere ca. 80 % eine 6-Monats-Kontrolle. ...
Article
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Zusammenfassung Hintergrund Allen Frauen in Deutschland im Alter von 50 bis 69 Jahren wird seit 2009 flächendeckend ein qualitätsgesichertes Mammographie-Screening-Programm angeboten, das an die Europäischen Leitlinien angelehnt ist. Dieser Übersichtsartikel fasst den aktuellen Stand wissenschaftlicher Bewertungen dieses nationalen Brustkrebs-Früherkennungsprogramms zusammen und gibt einen Ausblick auf laufende Studien zur Effektivitätsprüfung und Weiterentwicklung. Ergebnisse Aufgrund der erreichten Diagnosevorverlagerung mit Abnahme fortgeschrittener Brustkrebserkrankungen nach wiederholter Screening-Teilnahme ist ein Rückgang der brustkrebsspezifischen Mortalität zu erwarten; das Ausmaß wird die laufende ZEBra-Studie zur Mortalitätsevaluation zeigen. Schlussfolgerung Auf vier Feldern zeichnet sich Potenzial zur weiteren Effektivitätssteigerung der Brustkrebs-Früherkennung ab: 1. Frauen sollten das Früherkennungsangebot der Krankenkassen häufiger wahrnehmen; bisher nimmt durchschnittlich nur etwa jede zweite anspruchsberechtigte Frau zwischen 50 und 69 Jahren am Screening-Programm teil. 2. Erweiterung der Anspruchsberechtigung über das 70. Lebensjahr hinaus. 3. Die Weiterentwicklung der digitalen Mammographie zur digitalen Brust-Tomosynthese verspricht die Zahl falsch-positiver Rückrufe zu reduzieren bei gleichzeitiger Sensitivitätssteigerung. 4. Für die wenigen Frauen in der anspruchsberechtigen Gruppe mit extrem dichter Brust sind erweiterte Screening-Strategien wissenschaftlich zu überprüfen.
... The sensitivity of screening mammography in asymptomatic women with dense breasts was found to be 48% compared to 78% for the entire cohort of patients with the full range of breast density [61]. The use of DBT was found to lower recall rates and increase detection rates for women with dense breasts when comparing BI-RADs categories A and B to C and D [62,63]. When evaluating the highest density category alone (BI-RADS category D), however, there was no advantage to using DBT compared to digital mammograph [31,63]. ...
Article
Full-text available
Obesity, diabetes, and inflammation increase the risk of breast cancer, the most common malignancy in women. One of the mainstays of breast cancer treatment and improving outcomes is early detection through imaging-based screening. There may be a role for individualized imaging strategies for patients with certain co-morbidities. Herein, we review the literature regarding the accuracy of conventional imaging modalities in obese and diabetic women, the potential role of anti-inflammatory agents to improve detection, and the novel molecular imaging techniques that may have a role for breast cancer screening in these patients. We demonstrate that with conventional imaging modalities, increased sensitivity often comes with a loss of specificity, resulting in unnecessary biopsies and overtreatment. Obese women have body size limitations that impair image quality, and diabetes increases the risk for dense breast tis-sue. Increased density is known to obscure the diagnosis of cancer on routine screening mammography. Novel molecu-lar imaging agents with targets such as estrogen receptor, human epidermal growth factor receptor 2 (HER2), pyrimi-dine analogues, and ligand-targeted receptor probes, among others, have potential to reduce false positive results. They can also improve detection rates with increased resolution and inform therapeutic decision making. These emerg-ing imaging techniques promise to improve breast cancer diagnosis in obese patients with diabetes who have dense breasts, but more work is needed to validate their clinical application.
... DBT has been gaining popularity over digital mammography for higher image quality, richer structural detail, and better reduction in background signal noise [56]. In addition, recent studies [6], [57]- [60] have shown increased cancer detection rate with DBT in women aged 40 to 79 years with dense and non-dense breast, but results on reduced recall rate remains conflicted. Moreover, [6], [58]- [60] have shown that DBT reduces recall rates for women aged 40 to 79 years with dense and non-dense breast, but [61], [62] shown recall rates of DBT plus DM similar to that of DM alone. ...
Preprint
Deep learning has introduced several learning-based methods to recognize breast tumours and presents high applicability in breast cancer diagnostics. It has presented itself as a practical installment in Computer-Aided Diagnostic (CAD) systems to further assist radiologists in diagnostics for different modalities. A deep learning network trained on images provided by hospitals or public databases can perform classification, detection, and segmentation of lesion types. Significant progress has been made in recognizing tumours on 2D images but recognizing 3D images remains a frontier so far. The interconnection of deep learning networks between different fields of study help propels discoveries for more efficient, accurate, and robust networks. In this review paper, the following topics will be explored: (i) theory and application of deep learning, (ii) progress of 2D, 2.5D, and 3D CNN approaches in breast tumour recognition from a performance metric perspective, and (iii) challenges faced in CNN approaches.
... Our results suggest no reduction of interval cancers for women aged 50 years or over but a reduction in interval cancers in women aged 45-49. For the moment, other large studies have suggested greater benefits from introducing DBT in terms of screening performance in women younger than age 50 (4,24). Data from the BreastScreen Norway cohort study showed, consistent with our data, that the increase in detection obtained with DBT at the first round, compared with DM detection, is not compensated by a decrease at the following round (25). ...
Article
Background Adding digital breast tomosynthesis (DBT) to digital mammography (DM) improves breast cancer screening sensitivity, but how this impacts mortality and other end points is unknown. Purpose To compare interval and overall breast cancer incidence after screening with DBT plus DM versus DM alone. Materials and Methods In this prospective trial (RETomo), women attending screening were randomized to one round of DBT plus DM (experimental arm) or to DM (control arm). All were then rescreened with DM after 12 months (women aged 45-49 years) or after 24 months (50-69 years). The primary outcome was interval cancer incidence. Cumulative incidence up to the subsequent screening round plus 9 months (21- and 33-month follow-up for women aged 45-49 and 50-69, respectively) was also reported. Ductal carcinomas in situ are included. Subgroup analyses by age and breast density were conducted; 95% CIs computed according to binomial distribution are reported. Results Baseline cancer detection was higher in the DBT plu DM arm than DM arm (101 of 13 356 women vs 61 of 13 521 women; relative detection, 1.7 [95% CI: 1.2, 2.3]). The mean age ± standard deviation for the women in both arms was 55 years ± 7. Interval cancer incidence was similar in the two arms (21 vs 22 cancers; relative incidence, 0.97 [95% CI: 0.53, 1.8]). Cumulative incidence remained higher in the DBT plus DM arm in women over 50 (153 vs 124 cancers; relative incidence, 1.2 [95% CI: 0.99, 1.6]), while it was similar in the two arms in women aged 45-49 (36 vs 41 cancers; relative incidence, 0.89 [95% CI: 0.57, 1.4]). Conclusion In women younger than 50 years, the benefit of early diagnosis seemed to be appreciable, while for women over age 50, the higher sensitivity of tomosynthesis plus mammography was not matched by a subsequent reduction in cancers at the next screening examination or in the intervening interval. Clinical trial registration no. NCT02698202 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee and Ray in this issue.
... Our results suggest no reduction of interval cancers for women aged 50 years or over but a reduction in interval cancers in women aged 45-49. For the moment, other large studies have suggested greater benefits from introducing DBT in terms of screening performance in women younger than age 50 (4,24). Data from the BreastScreen Norway cohort study showed, consistent with our data, that the increase in detection obtained with DBT at the first round, compared with DM detection, is not compensated by a decrease at the following round (25). ...
... In a study by Rosner et al. [47,48], the findings showed that family and personal history of breast cancer were two of the key influential factors in breast cancer, which are consistent with the findings of the current study as these two factors demonstrated the highest weight (0.92 and 0.89) compared to other factors. Breast density and age are influential in tumor appearance and increase the proportion of breast cancers [49] with the weights (0.80, 0.80), respectively. However, the hysterec-tomy feature was used along with other risk factors that could influence the performance of models. ...
Article
Full-text available
Background: Breast cancer is considered one of the most common cancers in women caused by various clinical, lifestyle, social, and economic factors. Machine learning has the potential to predict breast cancer based on features hidden in data. Objective: This study aimed to predict breast cancer using different machine-learning approaches applying demographic, laboratory, and mammographic data. Material and methods: In this analytical study, the database, including 5,178 independent records, 25% of which belonged to breast cancer patients with 24 attributes in each record was obtained from Motamed cancer institute (ACECR), Tehran, Iran. The database contained 5,178 independent records, 25% of which belonged to breast cancer patients containing 24 attributes in each record. The random forest (RF), neural network (MLP), gradient boosting trees (GBT), and genetic algorithms (GA) were used in this study. Models were initially trained with demographic and laboratory features (20 features). The models were then trained with all demographic, laboratory, and mammographic features (24 features) to measure the effectiveness of mammography features in predicting breast cancer. Results: RF presented higher performance compared to other techniques (accuracy 80%, sensitivity 95%, specificity 80%, and the area under the curve (AUC) 0.56). Gradient boosting (AUC=0.59) showed a stronger performance compared to the neural network. Conclusion: Combining multiple risk factors in modeling for breast cancer prediction could help the early diagnosis of the disease with necessary care plans. Collection, storage, and management of different data and intelligent systems based on multiple factors for predicting breast cancer are effective in disease management.
... The estimated dose to the uterus exposure is less than 0.03 Gy, (23) which is significantly below the acceptable fetal exposure which is <50,000 Gy (24). The sensitivity of mammogram is low in women under the age of 40 due to increased parenchymal density of the breast tissue (25). However, mammography is helpful in evaluat-ing the contralateral breast as well as detection of microcalcifications which may not be visualized on ultrasound. ...
Article
Breast cancer is the second most common malignancy affecting pregnant women. Ductal carcinoma in situ (DCIS) during pregnancy has not been well described with limited literature addressing the optimal treatment options. This is important topic as the incidence of pregnancy-associated breast cancer (PABC) has been increasing. In the United States, 1 in 3000 pregnancies are complicated by breast cancer diagnosis. Most DCIS are screen detected as most patients are asymptomatic. Since routine screening mammogram is not recommended during pregnancy, diagnosis of DCIS without invasive disease is uncommon diagnosis. Although PABC is reported to account for 0.2-3.8% of all newly diagnosed breast cancer, it has not been defined between the diagnosis of DCIS or invasive breast cancer making true incidence of DCIS in pregnancy difficult to report. This review summarizes multidisciplinary recommendations for optimal treatment for DCIS diagnosed during pregnancy.
Article
Importance: Screening mammography and magnetic resonance imaging (MRI) are recommended for women with ATM, CHEK2, and PALB2 pathogenic variants. However, there are few data to guide screening regimens for these women. Objective: To estimate the benefits and harms of breast cancer screening strategies using mammography and MRI at various start ages for women with ATM, CHEK2, and PALB2 pathogenic variants. Design, setting, and participants: This comparative modeling analysis used 2 established breast cancer microsimulation models from the Cancer Intervention and Surveillance Modeling Network (CISNET) to evaluate different screening strategies. Age-specific breast cancer risks were estimated using aggregated data from the Cancer Risk Estimates Related to Susceptibility (CARRIERS) Consortium for 32 247 cases and 32 544 controls in 12 population-based studies. Data on screening performance for mammography and MRI were estimated from published literature. The models simulated US women with ATM, CHEK2, or PALB2 pathogenic variants born in 1985. Interventions: Screening strategies with combinations of annual mammography alone and with MRI starting at age 25, 30, 35, or 40 years until age 74 years. Main outcomes and measures: Estimated lifetime breast cancer mortality reduction, life-years gained, breast cancer deaths averted, total screening examinations, false-positive screenings, and benign biopsies per 1000 women screened. Results are reported as model mean values and ranges. Results: The mean model-estimated lifetime breast cancer risk was 20.9% (18.1%-23.7%) for women with ATM pathogenic variants, 27.6% (23.4%-31.7%) for women with CHEK2 pathogenic variants, and 39.5% (35.6%-43.3%) for women with PALB2 pathogenic variants. Across pathogenic variants, annual mammography alone from 40 to 74 years was estimated to reduce breast cancer mortality by 36.4% (34.6%-38.2%) to 38.5% (37.8%-39.2%) compared with no screening. Screening with annual MRI starting at 35 years followed by annual mammography and MRI at 40 years was estimated to reduce breast cancer mortality by 54.4% (54.2%-54.7%) to 57.6% (57.2%-58.0%), with 4661 (4635-4688) to 5001 (4979-5023) false-positive screenings and 1280 (1272-1287) to 1368 (1362-1374) benign biopsies per 1000 women. Annual MRI starting at 30 years followed by mammography and MRI at 40 years was estimated to reduce mortality by 55.4% (55.3%-55.4%) to 59.5% (58.5%-60.4%), with 5075 (5057-5093) to 5415 (5393-5437) false-positive screenings and 1439 (1429-1449) to 1528 (1517-1538) benign biopsies per 1000 women. When starting MRI at 30 years, initiating annual mammography starting at 30 vs 40 years did not meaningfully reduce mean mortality rates (0.1% [0.1%-0.2%] to 0.3% [0.2%-0.3%]) but was estimated to add 649 (602-695) to 650 (603-696) false-positive screenings and 58 (41-76) to 59 (41-76) benign biopsies per 1000 women. Conclusions and relevance: This analysis suggests that annual MRI screening starting at 30 to 35 years followed by annual MRI and mammography at 40 years may reduce breast cancer mortality by more than 50% for women with ATM, CHEK2, and PALB2 pathogenic variants. In the setting of MRI screening, mammography prior to 40 years may offer little additional benefit.
Article
Background: Digital breast tomosynthesis (DBT) may have a higher cancer detection rate and lower recall compared to 2 D mammography for breast cancer screening. The goal of this study was to evaluate screening outcomes with DBT in a real-world cohort, and to characterize the population health impact of DBT as it is widely adopted. Methods: This was an observational study evaluating breast cancer screening outcomes among women screened with 2 D mammography versus DBT. We used deidentified administrative data from a large, private health insurer and included women 40-64 screened between January 2015 to December 2017. Outcomes included recall, biopsy, and incident cancers detected. We used two complementary techniques a patient-level analysis using multivariable logistic regression and an area-level analysis evaluating the relationship between population-level adoption of DBT use and outcomes. All statistical tests were 2-sided. Results: Our sample included 7,602,869 mammograms in 4,580,698 women, 27.5% of whom received DBT. DBT was associated with modestly lower recall compared to 2 D mammography (113.6 [99% CI = 113.0-114.2] vs 115.4 [99% CI = 115.0-115.8] per 1,000 screens, p < .001), although younger women ages 40-44 had a larger reduction in recall (153 [99% CI = 151-15] vs 164 [99% CI = 163-166] per 1000 screens, p < .001). DBT was associated with higher biopsy rates than 2 D mammography (19.6 [99% CI = 19.3-19.8] vs 15.2 [99% CI = 15.1-15.4] per 1,000 screens, p < .001) and a higher cancer detection rate (4.9 [99% CI = 4.7-5.0] vs 3.8 [99% CI = 3.7-3.9] per 1,000, p < .001). Point estimates from the area-level analysis generally supported these findings. Conclusions: In a large population of privately insured women, DBT was associated with a slightly lower recall rate than 2 D mammography and a higher cancer detection rate. Whether this increased cancer detection improves clinical outcomes remains unknown.
Article
Resumen Objetivo revisar y evaluar los metaanálisis sobre la tomosíntesis digital para el cribado del cáncer de mama. Métodos se realizó una revisión sistemática de los estudios de metaanálisis utilizando los términos de búsqueda «Digital breast tomosynthesis for breast cancer screening» en las bases de datos PubMed y Embase. Los metaanálisis finalmente seleccionados se calificaron con la herramienta de evaluación AMSTAR 2. Resultados las búsquedas en las bases de datos encontraron 195 artículos de los cuales, después del cribado y la lectura completa de los artículos seleccionados, finalmente se extrajeron 5 para análisis cualitativo. La calificación de los metaanálisis revisados con la herramienta de evaluación AMSTAR 2 encontró que la confianza general de sus resultados es críticamente baja. Conclusiones los metaanálisis evaluados concluyeron en que hay un aumento en la tasa de detección del cáncer con la inclusión de la tomosíntesis digital en el cribado del cáncer de mama. Sin embargo, este estudio encontró con el uso de la herramienta de evaluación AMSTAR 2, que los resultados de los metaanálisis evaluados, no son confiables en el resumen que hacen de sus estudios.
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Importance: Digital breast tomosynthesis (DBT) has reduced recall and increased cancer detection compared with digital mammography (DM), depending on women's age and breast density. Whether DBT screening access and use are equitable across groups of women based on race/ethnicity and socioeconomic characteristics is uncertain. Objective: To determine women's access to and use of DBT screening based on race/ethnicity, educational attainment, and income. Design, setting, and participants: This cross-sectional study included 92 geographically diverse imaging facilities across 5 US states, at which a total of 2 313 118 screening examinations were performed among women aged 40 to 89 years from January 1, 2011, to December 31, 2017. Data were analyzed from June 13, 2019, to August 18, 2020. Exposures: Women's race/ethnicity, educational level, and community-level household income. Main outcomes and measures: Access to DBT (on-site access) at time of screening by examination year and actual use of DBT vs DM screening by years since facility-level DBT adoption (≤5 years). Results: Among the 2 313 118 screening examinations included in the analysis, the proportion of women who had DBT access at the time of their screening appointment increased from 11 558 of 354 107 (3.3%) in 2011 to 194 842 of 235 972 (82.6%) in 2017. In 2012, compared with White women, Black (relative risk [RR], 0.05; 95% CI, 0.03-0.11), Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly less DBT access, and women with less than a high school education had lower DBT access compared with college graduates (RR, 0.18; 95% CI, 0.10-0.32). Among women attending facilities with both DM and DBT available at the time of screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] to 0.98 [95% CI, 0.97-0.99]); women with lower educational level experienced lower DBT use (RRs, 0.79 [95% CI, 0.74-0.84] to 0.88 [95% CI, 0.85-0.91] for non-high school graduates and 0.90 [95% CI, 0.89-0.92] to 0.96 [95% CI, 0.93-0.99] for high school graduates vs college graduates); and women within the lowest income quartile experienced lower DBT use vs women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]) regardless of the number of years after facility-level DBT adoption. Conclusions and relevance: In this cross-sectional study, women of minority race/ethnicity and lower socioeconomic status experienced lower DBT access during the early adoption period and persistently lower DBT use when available over time. Future efforts should address racial/ethnic, educational, and financial barriers to DBT screening.
Article
Background: Contrast-enhanced digital mammography (CEDM) has been shown to outperform standard mammography while performing comparably to contrast-enhanced MRI. Objective: To compare imaging characteristics of false-positive and true-positive findings on CEDM. Methods: This retrospective study included women who underwent baseline screening CEDM between January 2013 and December 2018 assessed as BI-RADS category 0, 3, 4, or 5 and who underwent biopsy with histopathologic diagnosis or had two-year imaging follow-up. Lesion characteristics were extracted from CEDM reports. A true-positive finding was defined as a lesion in which biopsy yielded malignancy. A false-positive finding was defined as a lesion in which biopsy yielded benign or benign high-risk pathology, or two-year imaging follow-up was negative. Results: Of 157 patients (median age, 52 years), 24 had a total of 26 true-positive lesions, and 133 had a total of 147 false-positive lesions. Of the 26 true-positive lesions, 1 (4%) exhibited only a mammographic finding on low-iodine images, 13 (50%) only a contrast finding on iodine images, and 12 (46%) both a mammographic finding on low-energy images and a contrast finding on iodine images. A true-positive result was more likely (p=.02) for lesions present on both low-energy and iodine images (31%) than on low-energy images only (4%) or iodine images only (12%). Among lesions present on both low-energy and iodine images, a true-positive result was more likely (p<.001) when the type of mammographic finding was asymmetry (50%) or calcification (80%) than mass (11%) or distortion (0%). A true-positive result was more likely (p=.01) among those with, versus without, an ultrasound correlate (36% vs 9%), and also more likely (p=.02) among those with, versus without, an MRI correlate (18% vs 2%). Of 25 false-positive calcifications, 24 had no associated mammographic enhancement; of 5 true-positive calcifications, 4 had mammographic enhancement. Conclusion: A low-energy mammographic finding with associated enhancement, or a finding with sonographic or MRI correlate, predicts a true-positive result. Calcifications with associated enhancement had a high malignancy rate. Nonetheless, half of true-positive lesions enhanced on iodine images without a mammographic finding on low-energy images. Clinical impact: These observations inform radiologists' management of abnormalities detected on screening CEDM.
Article
Importance: Breast cancer screening with digital breast tomosynthesis may decrease false-positive results compared with digital mammography. Objective: To estimate the probability of receiving at least 1 false-positive result after 10 years of screening with digital breast tomosynthesis vs digital mammography in the US. Design, setting, and participants: An observational comparative effectiveness study with data collected prospectively for screening examinations was performed between January 1, 2005, and December 31, 2018, at 126 radiology facilities in the Breast Cancer Surveillance Consortium. Analysis included 903 495 individuals aged 40 to 79 years. Data analysis was conducted from February 9 to September 7, 2021. Exposures: Screening modality, screening interval, age, and Breast Imaging Reporting and Data System breast density. Main outcomes and measures: Cumulative risk of at least 1 false-positive recall for further imaging, short-interval follow-up recommendation, and biopsy recommendation after 10 years of annual or biennial screening with digital breast tomosynthesis vs digital mammography, accounting for competing risks of breast cancer diagnosis and death. Results: In this study of 903 495 women, 2 969 055 nonbaseline screening examinations were performed with interpretation by 699 radiologists. Mean (SD) age of the women at the time of the screening examinations was 57.6 (9.9) years, and 58% of the examinations were in individuals younger than 60 years and 46% were performed in women with dense breasts. A total of 15% of examinations used tomosynthesis. For annual screening, the 10-year cumulative probability of at least 1 false-positive result was significantly lower with tomosynthesis vs digital mammography for all outcomes: 49.6% vs 56.3% (difference, -6.7; 95% CI, -7.4 to -6.1) for recall, 16.6% vs 17.8% (difference, -1.1; 95% CI, -1.7 to -0.6) for short-interval follow-up recommendation, and 11.2% vs 11.7% (difference, -0.5; 95% CI, -1.0 to -0.1) for biopsy recommendation. For biennial screening, the cumulative probability of a false-positive recall was significantly lower for tomosynthesis vs digital mammography (35.7% vs 38.1%; difference, -2.4; 95% CI, -3.4 to -1.5), but cumulative probabilities did not differ significantly by modality for short-interval follow-up recommendation (10.3% vs 10.5%; difference, -0.1; 95% CI, -0.7 to 0.5) or biopsy recommendation (6.6% vs 6.7%; difference, -0.1; 95% CI, -0.5 to 0.4). Decreases in cumulative probabilities of false-positive results with tomosynthesis vs digital mammography were largest for annual screening in women with nondense breasts (differences for recall, -6.5 to -12.8; short-interval follow-up, 0.1 to -5.2; and biopsy recommendation, -0.5 to -3.1). Regardless of modality, cumulative probabilities of false-positive results were substantially lower for biennial vs annual screening (overall recall, 35.7 to 38.1 vs 49.6 to 56.3; short-interval follow-up, 10.3 to 10.5 vs 16.6 to 17.8; and biopsy recommendation, 6.6 to 6.7 vs 11.2 to 11.7); older vs younger age groups (eg, among annual screening in women ages 70-79 vs 40-49, recall, 39.8 to 47.0 vs 60.8 to 68.0; short-interval follow-up, 13.3 to 14.2 vs 20.7 to 20.9; and biopsy recommendation, 9.1 to 9.3 vs 13.2 to 13.4); and women with entirely fatty vs extremely dense breasts (eg, among annual screening in women aged 50-59 years, recall, 29.1 to 36.3 vs 58.8 to 60.4; short-interval follow-up, 8.9 to 11.6 vs 19.5 to 19.8; and biopsy recommendation, 4.9 to 8.0 vs 15.1 to 15.3). Conclusions and relevance: In this comparative effectiveness study, 10-year cumulative probabilities of false-positive results were lower on digital breast tomosynthesis vs digital mammography. Biennial screening interval, older age, and nondense breasts were associated with larger reductions in false-positive probabilities than screening modality.
Article
Background Since 2007, digital mammography and digital breast tomosynthesis (DBT) replaced screen-film mammography. Whether these technologic advances have improved diagnostic performance has, to the knowledge of the authors, not yet been established. Purpose To evaluate the performance and outcomes of surveillance mammography (digital mammography and DBT) performed from 2007 to 2016 in women with a personal history of breast cancer and compare with data from 1996 to 2007 and the performance of digital mammography screening benchmarks. Materials and Methods In this observational cohort study, five Breast Cancer Surveillance Consortium registries provided prospectively collected mammography data linked with tumor registry and pathologic outcomes. This study identified asymptomatic women with American Joint Committee on Cancer anatomic stages 0-III primary breast cancer who underwent surveillance mammography from 2007 to 2016. The primary outcome was a second breast cancer diagnosis within 1 year of mammography. Performance measures included the recall rate, cancer detection rate, interval cancer rate, positive predictive value of biopsy recommendation, sensitivity, and specificity. Results Among 32 331 women who underwent 117 971 surveillance mammographic examinations (112 269 digital mammographic examinations and 5702 DBT examinations), the mean age at initial diagnosis was 59 years ± 12 (standard deviation). Of 1418 second breast cancers diagnosed, 998 were surveillance-detected cancers and 420 were interval cancers. The recall rate was 8.8% (10 365 of 117 971; 95% CI: 8.6%, 9.0%), the cancer detection rate was 8.5 per 1000 examinations (998 of 117 971; 95% CI: 8.0, 9.0), the interval cancer rate was 3.6 per 1000 examinations (420 of 117 971; 95% CI: 3.2, 3.9), the positive predictive value of biopsy recommendation was 31.0% (998 of 3220; 95% CI: 29.4%, 32.7%), the sensitivity was 70.4% (998 of 1418; 95% CI: 67.9%, 72.7%), and the specificity was 98.1% (114 331 of 116 553; 95% CI: 98.0%, 98.2%). Compared with previously published studies, interval cancer rate was comparable with rates from 1996 to 2007 in women with a personal history of breast cancer and was higher than the published digital mammography screening benchmarks. Conclusion In transitioning from screen-film to digital mammography and digital breast tomosynthesis, surveillance mammography performance demonstrated minimal improvement over time and remained inferior to the performance of screening mammography benchmarks. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Moy and Gao in this issue.
Article
Purpose Review of outcomes of screening patients imaged with both digital breast tomosynthesis (DBT) and screening ultrasound (US) to compare the cancer detection rates and characteristics of cancers detected by the imaging modalities. Material and Methods This retrospective study reviewed a total of 24,787 screening US exams performed in the time period of January 2013 through December 2017. These exams were in patients with heterogeneously dense or extremely dense breast tissue. In this population, 21,220 (86%) had DBT screening mammography. These cases were further reviewed to identify any pathology-proven malignancy detected with US and/or DBT. Results The study cohort consisted of 115 breast cancers in patients having screening US and DBT. Of the 115 cancers, 100 were invasive cancers and 15 were ductal carcinoma in situ: 64/115 were seen on DBT, 9 of which were seen only on DBT, and 106 were seen on US, with 51 seen only on US. The cancer detection rate of DBT only was 0.4/1000 (9/21,220) and 3.0/1000 (64/21,220) for those detected on DBT whether with or without additional US, with detection on US only having an incremental cancer detection rate of 2.4/1000 (51/21,220) above DBT detected malignancies. Differences in DBT-detected lesions and US only lesions when comparing median lesion size, lesion type, tumor type (invasive vs noninvasive) and tumor stage were statistically significant (p = 0.0045, p = 0.0113, p = 0.0003, and p = 0.0153, respectively). Conclusion In review of the outcomes of a screening US program, we found a similar number of breast cancers were detected by DBT and US, and US alone (47.8% vs 44.3%, respectively). Ninety-six percent of the cancers detected by US alone were invasive; 89% of those seen on both modalities were invasive, while most of the breast cancers seen on DBT only were in situ carcinoma. Statistically significant differences between DBT and US, and US alone were found for many lesion characteristics including lesion size, type, tumor size, and tumor stage.
Article
OBJECTIVE. One central question pertaining to mammography quality relates to discerning the optimal recall rate to maximize cancer detection while minimizing unnecessary downstream diagnostic imaging and breast biopsies. We examined the trade-offs for higher recall rates in terms of biopsy recommendations and cancer detection in a single large health care organization. MATERIALS AND METHODS. We included 2D analog, 2D digital, and 3D digital (tomosynthesis) screening mammography examinations among women 40-79 years old performed between January 1, 2005, and December 31, 2017, with cancer follow-up through 2018. There were 36, 67, and 38 radiologists who read at least 1000 2D analog examinations, 2D digital examinations, and 3D tomosynthesis examinations, respectively, who were included in these analyses. Using logistic regression with marginal standardization, we estimated radiologist-specific mean recall (abnormal interpretations/1000 mammograms), biopsy recommendation, cancer detection (screening-detected in situ and invasive cancers/1000 mammograms), and minimally invasive cancer detection rates while adjusting for differences in patient characteristics. RESULTS. Among 1,060,655 screening mammograms, the mean recall rate was 10.7%, the cancer detection rate was 4.0/1000 mammograms, and the biopsy recommendation rate was 1.60%. Recall rates between 7% and 9% appeared to maximize cancer detection while minimizing unnecessary biopsies. CONCLUSION. The results of this investigation are in contrast to those of a recent study suggesting appropriateness of higher recall rates. The "sweet spot" for optimal cancer detection appears to be in the recall rate range of 7-9% for both 2D digital mammography and 3D tomosynthesis. Too many women are being called back for diagnostic imaging, and new benchmarks could be set to reduce this burden.
Article
Background Two dimensional (2D) full-field digital mammography is the current standard of breast cancer screening. Digital breast tomosynthesis generates pseudo-three dimensional datasets of the breast from which synthesised 2D (s2D) mammograms can be reconstructed. This innovative approach reduces the likelihood of overlapping breast tissues that can conceal features of malignancy. We aimed to compare digital breast tomosynthesis plus s2D mammography with digital screening mammography for the detection of invasive breast cancer. Methods TOSYMA was a randomised, open-label, superiority trial done at 17 screening units in two federal states of Germany. Eligible participants were women aged 50–69 years who had been invited to participate in a population-wide, quality-controlled mammography screening programme. Women were randomly assigned (1:1) to digital breast tomosynthesis plus s2D mammography or digital mammography alone using block randomisation (block size of 32), stratified by site. The primary endpoints were the detection rate of invasive breast cancer and invasive interval cancer rate at 24 months, analysed in the modified full analysis set, which included all randomly assigned participants who underwent either type of screening examination. Ten examinations, corresponding to a second study participation, were excluded. Analyses were done according to the intention-to-treat principle. Interval cancer rates will be reported in the follow-up study. Safety was assessed in the as-treated population, which included all participants who were randomly assigned. This trial is registered with ClinicalTrials.gov, NCT03377036, and is closed to accrual. Findings Between July 5, 2018, and Dec 30, 2020, 99 689 women were randomly assigned to digital breast tomosynthesis plus s2D mammography (n=49 804) or digital mammography (n=49 830). Invasive breast cancers were detected in 354 of 49 715 women with evaluable primary endpoint data in the digital breast tomosynthesis plus s2D group (detection rate 7·1 cases per 1000 women screened) and in 240 of 49 762 women in the digital mammography group (4·8 cases per 1000 women screened; odds ratio 1·48 [95% CI 1·25–1·75]; p<0·0001). Adverse events and device deficiencies were rare (six adverse events in each group; 23 device deficiencies in the digital breast tomosynthesis plus s2D group vs five device deficiencies in the digital mammography group) and no serious adverse events were reported. Interpretation The results from this study indicate that the detection rate for invasive breast cancer was significantly higher with digital breast tomosynthesis plus s2D mammography than digital mammography alone. Evaluation of interval cancer rates in the follow-up study will further help to investigate incremental long-term benefits of digital breast tomosynthesis screening. Funding Deutsche Forschungsgemeinschaft (German Research Foundation).
Article
Objectives This systematic review and meta-analysis focuses on breast cancer screening performance outcomes stratified into breast density, age, and reading procedure using ‘digital breast tomosynthesis (DBT) with synthesised two-dimensional mammography (s2D)’ compared to ‘digital mammography (DM) alone’. Methods Studies comparing ‘DBT with s2D’ and ‘DM’ were searched in PubMed and Cochrane library. Pooled risk ratios (RR) using fixed or random effects models (F-/REM) for cancer detection rates (CDR), recall rates, interval cancer rates (ICR), biopsy rates, and positive predictive values (PPV) 1-3 were calculated. Outcomes were stratified into breast density (non-dense and dense), age (< 60, ≥ 60), and reading procedure (double-/ non-double reading). Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. Results We identified 13 studies. Using DBT plus s2D compared to DM alone resulted in a higher increase in CDR for dense ([number of studies included, FEM RR, 95% confidence interval (CI)]; n=3, 1.60, 1.16-2.22) versus non-dense breasts (n=3, 1.32, 1.08-1.61). Recall rates were lower in dense (n=2, 0.84, 0.75-0.94), but much lower for non-dense breasts (n=2, 0.65, 0.59-0.72). Age stratification resulted in small differences in CDR (<60: n=2, 1.64, 1.18-2.29 / ≥60: n=2, 1.56, 1.19-2.05). After screening with DBT plus s2D compared to DM alone the risk of being recalled was less in non-double (n=3, 0.57, 0.54-0.60) than in double reading (n=5, 0.95, 0.81-1.11) and the risk of cancer detection was higher in double reading (n=6, 1.53, 1.40-1.67) than in non-double reading (n=4, 1.17, 1.02-1.33). Conclusion Since only few studies are available for meta-analyses statistical significance strongly depends on single study results. Taking this into account, the most important results concern the increase of CDR in women with dense breasts, the increased CDR in double reading, and the lower recall rates particularly with non-double reading.
Article
Background Prevalent digital breast tomosynthesis (DBT) has shown higher cancer detection rates and lower recall rates compared with those of digital mammography (DM). However, data are limited on rates and histopathologic tumor characteristics of interval and subsequent round screen-detected cancers for DBT. Purpose To follow women randomized to screening with DBT or DM and to investigate rates and tumor characteristics of interval and subsequent round screen-detected cancers. Materials and Methods To-Be is a randomized controlled trial comparing the outcome of DBT and DM in organized breast cancer screening. The trial included 28 749 women, with 22 306 women returning for subsequent DBT screening 2 years later (11 201 and 11 105 originally screened with DBT and DM, respectively). Differences in rates, means, and distribution of histopathologic tumor characteristics between women prevalently screened with DBT versus DM were evaluated with Z tests, t tests, and χ2 tests. Relative risk (RR) with 95% CIs was calculated for the cancer rates. Results Interval cancer rates were 1.4 per 1000 screens (20 of 14 380; 95% CI: 0.9, 2.1) for DBT versus 2.0 per 1000 screens (29 of 14 369; 95% CI: 1.4, 2.9; P = .20) for DM. The rates of subsequent round screen-detected cancer were 8.1 per 1000 (95% CI: 6.6, 10.0) for women originally screened with DBT and 9.1 per 1000 (95% CI: 7.4, 11.0; P = .43) for women screened with DM. The distribution of tumor characteristics did not differ between groups for either interval or subsequent screen-detected cancer. The RR of interval cancer was 0.69 (95% CI: 0.39, 1.22; P = .20) for DBT versus DM, whereas RR of subsequent screen-detected cancer for women prevalently screened with DBT versus DM was 0.89 (95% CI: 0.67, 1.19; P = .43). Conclusion Rates of interval or subsequent round screen-detected cancers and their tumor characteristics did not differ between women originally screened with digital breast tomosynthesis (DBT) versus digital mammography. The analysis suggests that the benefits of prevalent DBT screening did not come at the expense of worse downstream screening performance measures in a population-based screening program. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Taourel in this issue.
Article
Objectives: To compare abnormal call rates (ACR), cancer detection rates (CDR), positive predictive values (PPVs), and annual return to screen recommendations after switching from digital mammography (DM) to digital breast tomosynthesis plus DM (DBT + DM) for breast cancer screening. Setting: The Alberta Breast Cancer Screening Program collects screening data from clinics throughout the province of Alberta, Canada. Methods: This study retrospectively collected data, between 2015 and 2018, on women aged 40+ who underwent breast cancer screening at two large volume multisite radiology groups to compare metrics one year prior and one year after DBT + DM implementation. Comparisons between modalities were carried out within age groups, within breast density categories, and for initial vs. subsequent screens. Results: A total of 125,432 DM and 128,912 DBT + DM screening exams were performed. For women aged 50-74, the DBT + DM group had a higher ACR (p < 0.01) but lower annual return to screens (p < 0.01). CDR was higher post-DBT + DM implementation for women with scattered (6.0 per 1000 vs. 4.4 per 1000; p = 0.001) or heterogeneously dense breasts (6.5 per 1000 vs. 4.2 per 1000; p < 0.001). PPV was higher with DBT + DM for all age groups, with women 50-74 having a PPV of 8.3% using DBT + DM vs. 7.1% with DM (p = 0.009). Conclusion: All metrics improved or stayed the same after switching to DBT + DM except for ACR. However, the increase in ACR could be attributed to a trend already occurring prior to the switch. Longer term monitoring is needed to confirm these findings.
Article
Digital breast tomosynthesis (DBT) is gradually being implemented in routine clinical breast imaging practice. The technique of image acquisition reduces the confounding effect of overlapping breast tissue, which substantially affects cancer detection, abnormal recall, and interval cancer rates in a screening/ surveillance setting. In a diagnostic setting, tomosynthesis also allows for improved lesion localization and characterization over conventional imaging, which potentially improves the accuracy and improved workflow efficiency. To optimize the utility of tomosynthesis, imagers should be aware of the pertinent aspects of image acquisition as it relates to interpretation, the appearance of benign and malignant pathologies, and sources of possible misinterpretation. This article aims to provide a practical knowledge base of DBT and demonstrate its potential benefits when incorporated into routine clinical practice.
Article
Rational and objective To investigate the utility of digital breast tomosynthesis (DBT) in the evaluation of focal breast pain, considering breast density and breast cancer risk. Methods Ninety-one cases of focal breast pain evaluated with DBT and ultrasound (US) from 12/30/2014 to 11/9/2017 with 2-year follow-up were identified. Exclusion criteria were non-focal, axillary, or radiating pain; palpable or skin changes; pregnancy or lactation; and history of ipsilateral cancer, trauma, or infection. Demographic data, Tyrer-Cuzick Score (TCS), medical history, breast density, imaging results, and pathology were recorded. Descriptive statistics were reported. Results Eighteen percent (16/91) of cases demonstrated findings, all benign. Of these, 6% (1/16) were detected by DBT only, 88% (14/16) by US only, and 6% (1/16) by DBT and US. US resulted in 3 benign biopsies. Ninety-nine percent (75/76) of cases with no findings at the site of pain on US also had no findings on DBT. Ninety-eight percent (89/91) of cases with no cancer detected at the site of pain on US also did not have cancer on DBT. DBT detected 2 incidental cancers not associated with pain. DBT and US agreed that there was no finding at the site of pain in 82% (75/91) of cases. A high degree of agreement between DBT and US was seen when stratified by breast density and TCS. Conclusion DBT may be appropriate for the evaluation of focal pain. Low breast cancer incidence was observed at the site of focal pain across all mammographic breast densities and breast cancer risks.
Article
Regular screening mammography reduces breast cancer mortality. However, in women with dense breasts, the performance of screening mammography is reduced, which is reflected in higher interval cancer rates (ICR). In Canada, population-based screening mammography programs generally screen women biennially; however, some provinces and territories offer annual mammography for women with dense breast tissue routinely and/or on recommendation of the radiologist. This study compared the ICRs in those breast screening programs with a policy of annual vs. those with biennial screening for women with dense breasts. Among 148,575 women with dense breasts screened between 2008 to 2010, there were 288 invasive interval breast cancers; screening programs with policies offering annual screening for women with dense breasts had fewer interval cancers 63/70,814 (ICR 0.89/1000, 95% CI: 0.67-1.11) compared with those with policies of usual biennial screening 225/77,761 (ICR 1.45 /1000 (annualized), 95% CI: 1.19-1.72) i.e. 63% higher (p = 0.0016). In screening programs where radiologists' screening recommendations were able to be analyzed, a total of 76,103 women were screened, with 87 interval cancers; the ICR was lower for recommended annual (65/69,650, ICR 0.93/1000, 95% CI: 0.71, 1.16) versus recommended biennial screening (22/6,453, ICR 1.70/1000 (annualized), 95%CI: 0.70, 2.71)(p = 0.0605). Screening program policies of annual as compared with biennial screening in women with dense breasts had the greatest impact on reducing interval cancer rates. We review our results in the context of current dense breast notification in Canada.
Breast imaging has evolved over several decades; however, a significant leap has happened in the past couple of decades. Multiple modalities are available for the evaluation of breast diseases; Mammography, Digital Breast Tomosynthesis, Ultrasound, Magnetic Resonance Imaging (MRI), and Contrast Enhanced Mammography (CEM) are a few of the frequently used ones. Image-guided interventions have further evolved, core needle biopsy, vacuum-assisted biopsy, clip placements, and wire localization to name a few. At times, it is difficult to choose between the modalities for disease evaluation and intervention. In this article, we have tried to cover in brief the evolution of breast imaging over years and have discussed the imaging approach to some frequent clinical presentations along with the approach to the evaluation of mammography.
Article
Background: Postoperative mammograms present interpretive challenges due to postoperative distortion and hematomas. The application of digital breast tomosynthesis (DBT) and artificial intelligence-based computer-aided detection (AI-CAD) after breast concerving therapy (BCT) has not been widely investigated. Objective: To assess the impact of additional DBT or AI-CAD on recall rate and diagnostic performance in women undergoing mammographic surveillance after BCT. Methods: This retrospective study included 314 women (mean age 53.2±10.6 years; 4 with bilateral breast cancer) who underwent BCT followed by DBT (mean interval from surgery to DBT of 15.2±15.4 months). Three breast radiologists independently reviewed images in three sessions: digital mammography (DM), DM with DBT (DM+DBT), and DM with AI-CAD (DM+AI-CAD). Recall rates and diagnostic performance were compared between DM, DM+DBT, and DM+AI-CAD, using readers' mean results. Results: Of the 314 women, 6 breast recurrences (3 ipsilateral, 3 contralateral) developed at the time of surveillance mammography. Ipsilateral breast recall rate was lower for DM+AI-CAD (1.9%) than for DM (11.2%) or DM+DBT (4.1%) (p<.001). Contralateral breast recall rate was lower for DM+AI-CAD (1.5%, p<.001) than for DM (6.6%) but not DM+DBT (2.7%, p=.08). In ipsilateral breast, accuracy was higher for DM+AI-CAD (97.0%) than for DM (88.5%) or DM+DBT (94.8%) (p<.05); specificity was higher for DM+AICAD (98.3%) than for DM (89.3%) or DM+DBT (96.1%) (p<.05); sensitivity was lower for DM+AI-CAD (22.2%) than for DM (66.7%, p=.03) but not DM+DBT (22.2%, p>.99). In contralateral breast, accuracy was higher for DM+AI-CAD (97.1%) than for DM (92.5%, p<.001) but not DM+DBT (96.1%, p=.25); specificity was higher for DM+AI-CAD (98.6%) than for DM (93.7%, p<.001) but not DM+DBT (97.5%) (p=.09); sensitivity was not different between DM (33.3%), DM+DBT (22.2%), and DM+AI-CAD (11.1%) (p>.05). Conclusion: After BCT, adjunct DBT or AI-CAD reduced recall rates and improved accuracy in the ipsilateral and contralateral breasts compared with DM. In the ipsilateral breast, addition of AI-CAD resulted in lower recall rate and higher accuracy than addition of DBT. Clinical Impact: AI-CAD may help address the challenges of post-BCT surveillance mammograms.
Article
Objective Compare the BI-RADS 3 rate and follow-up of dense breast ultrasound (US) screening following DM versus DBT. Methods IRB-approved, HIPAA compliant retrospective search was performed of databases at two tertiary breast centers and an office practice for BI-RADS 3 screening US examinations performed 10/1/14–9/30/16. Prior DM versus DBT, downgrade and upgrade rate and timing and pathology results were recorded. Differences were compared using the two-sample proportions test. Results 3183 screening US examinations were performed, 1434/3183 (45%) after DM and 1668/3183 (52.4%) after DBT (2.5% (81/3183) no prior mammogram available). 14% (199/1434) had BI-RADS 3 results after DM and 11% (177/1668) after DBT (p < 0.01). Median imaging follow-up after DBT was 12 months (IQR 6, 24) versus 18 after DM (IQR 11, 25), p = 0.02. 19.5% (73/375) of patients were lost to follow-up (19% (38/198) after DM (68.4% (26/38) no follow-up after initial exam) versus 20% (35/177) after DBT (54.3% (19/35) no follow-up after initial exam). 1.3% (5/375) of patients elected biopsy (1.5% (3/198) after DM and 1.1% (2/177) after DBT). 75.2% (282/375) of patients were downgraded (74% (149/198) after DM and 75% (133/177) after DBT). 2.5% (5/198) were upgraded after DM and 0.6% (1/177) after DBT. Median time to upgrade was 6 months after both DM and DBT. 0.3% (1/375) of patients with BI-RADS 3 results had cancer on follow-up. Conclusion Patients with prior DBT had a lower risk of encountering BI-RADS 3 findings on screening ultrasound. BI-RADS 3 findings on screening ultrasound had an extremely low rate of being cancer.
Article
Background Despite recent progress in liquid biopsy technologies, early blood-based detection of breast cancer is still a challenge. Methods We analyzed secretion of the protein cellular communication network factor 1 (CCN1, formerly cysteine-rich angiogenic inducer 61) in breast cancer cell lines by an enzyme-linked immunosorbent assay (ELISA). Soluble CCN1 in the plasma (2.5 µL) of 544 patients with breast cancer and 427 healthy controls was analyzed by ELISA. The breast cancer samples were acquired at the time of primary diagnosis prior to neoadjuvant therapy or surgery. A classifier was established on a training cohort of patients with breast cancer and age-adapted healthy controls and further validated on an independent cohort comprising breast cancer patients and healthy controls. Samples from patients with benign breast diseases were investigated as additional controls. Samples from patients with acute heart diseases (n = 127) were investigated as noncancer controls. The diagnostic accuracy was determined by receiver operating characteristic using the parameters area under the curve, sensitivity, and specificity. Results CCN1 was frequently secreted by breast cancer cell lines into the extracellular space. Subsequent analysis of clinical blood samples from patients with breast cancer and age-adjusted healthy controls revealed an overall specificity of 99.0% and sensitivity of 80.0% for cancer detection. Remarkably, 81.5% of small T1 cancers were already CCN1-positive, while CCN1 concentrations in patients with benign breast lesions were below the threshold for breast cancer detection. Conclusions Circulating CCN1 is a potentially novel blood biomarker for the detection of breast cancer at the earliest invasive stage.
Article
Background: Prior studies comparing screening by digital breast tomosynthesis (DBT) and digital mammography (DM) have largely entailed prospective trials and investigations at tertiary academic centers, which may encounter high risk patient populations and lack heterogeneity among interpreting radiologists. Thus, results may not generalize across real-world community settings in the United States. Objective: To compare DBT and DM in terms of screening performance and tumor characteristics of screen-detected cancers, in a community practice setting. Methods: Data were retrospectively retrieved for all screening mammograms performed by DBT or DM at four outpatient private practice facilities from 1/1/2012 to 7/10/2019. Examinations were interpreted by one of 26 radiologists (21 breast radiologists, 5 general radiologists). Further detailed information was recorded from radiology and pathology reports for all screen-detected cancers. Statistical comparisons were performed between DBT and DM in terms of screening performance and tumor characteristics of screen-detected cancers. Results: A total of 310 cancers were detected in 47,096 screening DBT examinations and 83,200 screening DM examinations. Cancer detection rate was higher (p<.001) for DBT (3.4 per 1000 women) than DM (1.8 per 1000 women). PPV1 was higher (p<.001) for DBT [3.5% (161/4641)] than DM [2.1% (149/7116)]. Age was lower (p=.02) for patients with screen-detected cancer by DBT (mean, 61 years; range, 40-87 years) than DM (mean, 64 years; range, 37-88 years). A greater percentage of DBT-detected than DM-detected cancers were invasive [85.1% (137/161) vs 72.5% (108/149), respectively; p=.006], grade 1 when invasive [27.9% (38/136) vs 17.8% (19/107), respectively; p=.04], and node negative [92.2% (71/77) vs 78.4% (58/74), respectively; p=.02]. Cancers detected by DBT and DM were not significantly different in histologic subtype, molecular subtype, or mean size (all p>.05). Conclusion: DBT demonstrated a higher cancer detection rate and PPV1 than DM; patients were younger at cancer diagnosis for DBT. Cancers detected on DBT were more often invasive, grade 1, and node-negative. Clinical Impact: The findings support the generalizability of insights into DBT-based screening, which previously have been investigated primarily in academic settings.
Article
Ductal carcinoma in situ (DCIS) is a heterogenous disease. The mainstay of its management is surgery, and lumpectomy with or without radiation therapy (RT) or mastectomy are standard options. Endocrine therapy may be given to maximize risk reduction. With standard treatment, the longterm breast cancer-specific survival is excellent and exceeds 95%. Currently, management strategies are based on standard clinicopathological features. Genomic tools to predict local recurrence have been developed, and prospective studies to evaluate their impact on RT recommendations and outcomes are ongoing. Because of concerns regarding overtreatment of DCIS, there has been much enthusiasm for de-escalating locoregional therapy. RT halves the risk of local recurrence but does not affect survival, and its omission can be considered in low-risk groups. Active surveillance for lowrisk DCIS is being evaluated in 4 prospective trials. The concern regarding these trials is whether the selected "low-risk" cases are truly at low risk, and what threshold of recurrence is considered acceptable. Additionally, it is unclear whether patients will be willing to trade short outpatient procedures for more biopsies, more imaging, and possibly increased concern about recurrence. The clinical relevance and the safety of this approach are yet to be determined.
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Imaging-guided percutaneous breast biopsy is of utmost importance in the evaluation of suspicious breast lesions and has become the standard of care prior to surgical management. Diagnosis can be achieved with minimal patient trauma on an outpatient and cost-effective basis, avoiding open surgery for benign results and providing critical information for malignant results, allowing preoperative staging, acquisition of histologic biomarkers, and planning for optimal surgical resection.
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Radiation-based breast imaging has undergone an impressive evolution in the past decades. Mammography is still the most used imaging method for screening and diagnostic workup in clinical practice. The transition from conventional screen-film mammography to full-field digital mammography (DM) and the addition of digital breast tomosynthesis (DBT) allowed higher diagnostic accuracy, especially for women with dense breasts. In this chapter, we will briefly discuss the technique of modern radiation-based breast imaging methods (DM and DBT), their indications, and basic interpretation.
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Breast cancer is the most common cancer in women, and hundreds of thousands of unnecessary biopsies are done around the world at a tremendous cost. It is crucial to reduce the rate of biopsies that turn out to be benign tissue. In this study, we build deep neural networks (DNNs) to classify biopsied lesions as being either malignant or benign, with the goal of using these networks as second readers serving radiologists to further reduce the number of false-positive findings. We enhance the performance of DNNs that are trained to learn from small image patches by integrating global context provided in the form of saliency maps learned from the entire image into their reasoning, similar to how radiologists consider global context when evaluating areas of interest. Our experiments are conducted on a dataset of 229,426 screening mammography examinations from 141,473 patients. We achieve an AUC of 0.8 on a test set consisting of 464 benign and 136 malignant lesions.
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Background To perform a systematic review and meta-analysis comparing the breast cancer detection rate (CDR), invasive CDR, recall rate, and positive predictive value 1 (PPV1) of digital breast tomosynthesis (DBT), combined DBT and digital mammography (DM), combined DBT and synthetic 2 D-mammography (S2D), and DM alone. Methods MEDLINE and Embase were searched until April 2020 to identify comparative design studies reporting on patients undergoing routine breast cancer screening. Random effects model proportional meta-analyses estimated CDR, invasive CDR, recall rate, and PPV1. Meta-regression modeling was utilized to compare imaging modalities. All statistical tests were two-sided. Results Forty-two studies reporting on 2,606,296 patients (13,003 breast cancer cases) were included. CDR was highest in combined DBT and DM (6.36 per 1,000 screened, 95% confidence interval [CI]=5.62–7.14; P < .001), and combined DBT and S2D (7.40 per 1,000 screened, 95% CI = 6.49–8.37; P < .001) compared to DM alone (4.68 per 1,000 screened, 95% CI = 4.28–5.11). Invasive CDR was highest in combined DBT and DM (4.53 per 1,000 screened, 95% CI = 3.97–5.12, P = .003), and combined DBT and S2D (5.68 per 1,000 screened, 95% CI = 4.43–7.09; P < .001) compared to DM alone (3.42 per 1,000 screened, 95% CI = 3.02–3.83). Recall rate was lowest in combined DBT and S2D (42.3%, 95% CI = 37.4%–60.4%, P < .001). PPV1 was highest in combined DBT and DM (10.0%, 95% CI = 8.0–12.0; P = .004), and combined DBT and S2D (16.0%, 95% CI = 10.0–23.0; P < .001), while no difference was detected for DBT alone (7.0%, 95% CI = 6.0%–8.0%; P = .75) compared to DM alone (7.0%, 95.0% CI = 5.0%–8.0%). Conclusion Our findings provide evidence on key performance metrics for DM, DBT alone, combined DBT and DM, and combined DBT and S2D, which may inform optimal application of these modalities for breast cancer screening.
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Background: The Verona population-based breast cancer (BC) screening program provides biennial mammography to women aged 50-69 years. Based on emerging evidence of enhanced detection, the program transitioned to digital breast tomosynthesis (DBT) screening. Methods: This is a prospective pilot evaluation of DBT with synthesised 2D mammography screening implemented during April 2015-March 2017; the rate and characteristics of cancers detected at DBT screening were compared with those detected at the preceding digital mammography (DM) screening round (April 2013-March 2015) in the same screening program. Distribution of imaging and tumour characteristics were compared. Results: Amongst 34,071 women screened in the Verona DBT pilot, 315 BCs were detected; 153 BCs were detected amongst 29,360 women in the DM screening round. Estimated CDRs were 9.2/1000 (95% CI 8.3-10.3) DBT screens versus 5.2/1000 (95% CI 4.4-6.1) DM screens, P < 0.001. Statistically significant differences were found in the distribution of whether recall by one/both screen readers (more BCs recalled by both readers at DBT than DM); whether detected on one/two views (higher proportion detected on only one view at DBT than DM); type of radiological lesions; tumour stage, pT and histological categories (lower proportion of DCIS/pTis, higher proportions of pT1a and pT1b, and higher proportion of invasive cancers of special types, at DBT than DM); and tumour grade (higher proportion of grade I at DBT than DM). There were no differences in distributions of nodal and hormone receptor (ER/PR) status. Conclusions: Our findings provide early insights into the extent that transitioning to DBT screening may modify the characteristics of screen-detected breast cancer to inform discussion regarding pros and cons of DBT screening; although our data provide some reassurance that DBT does not increase the proportion of screen-detected DCIS, they highlight mixed findings on comparative tumour characteristics, suggesting a potential for enhancing screening benefit and possibly also over-diagnosis from DBT screening.
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Purpose: To determine the effect of tomosynthesis imaging as a function of age for breast cancer screening. Methods: Screening performance metrics from 13 institutions were examined for 12 months prior to introduction of tomosynthesis (period 1) and compared to those after introduction of tomosynthesis (period 2, range 3-22 months). Screening metrics for women ages 40-49, 50-59, 60-69, and 70+ , included rates per 1000 screens for recalls, biopsies, cancers, and invasive cancers detected. Results: Performance parameters were compared for women screened with digital mammography alone (n = 278,908) and digital mammography + tomosynthesis (n = 173,414). Addition of tomosynthesis to digital mammography produced significant reductions in recall rates for all age groups and significant increases in cancer detection rates for women 40-69. Largest recall rate reduction with tomosynthesis was for women 40-49, decreasing from 137 (95% CI 117-156) to 115 (95% CI 95-135); difference, -22 (95% CI -26 to -18; P < .001). Simultaneous increase in invasive cancer detection rate for women 40-49 from 1.6 (95% CI 1.2-1.9) to 2.7 (95% CI 2.2-3.1) with tomosynthesis (difference, 1.1; 95% CI 0.6-1.6; P < .001) was observed. Conclusions: Addition of tomosynthesis to digital mammography increased invasive cancer detection rates for women 40-69 and decreased recall rates for all age groups with largest performance gains seen in women 40-49. The similar performance seen with tomosynthesis screening for women in their 40s compared to digital mammography for women in their 50s argues strongly for commencement of mammography screening at age 40 using tomosynthesis.
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Purpose: We evaluated the benefit of adding digital breast tomosynthesis (DBT) to full-field digital mammography (FFDM) compared to FFDM alone for breast cancer detection, focusing on cancer characteristics. Methods: We searched electronic databases and relevant references for published studies comparing DBT plus FFDM to FFDM alone for breast cancer screening. Pooled risk ratios (RRs) for various pathologic findings were determined using random effects models. Results: Eleven eligible studies were included. Pooled RRs showed a greater cancer detection for DBT plus FFDM than for FFDM alone for invasive cancer (1.327; 95% CI, 1.168-1.508), stage T1 (1.388; 95% CI, 1.137-1.695), nodal-negative (1.451; 95% CI, 1.209-1.742), all histologic grades (grade I, 1.812; grade II/III, 1.403), and histologic types of invasive cancer (ductal, 1.437; lobular, 1.901). However, adding DBT did not increase for detection of carcinoma in situ (1.198; 95% CI, 0.942-1.524), stage ≥T2 (1.391; 95% CI, 0.895-2.163), or nodal-positive cancer (1.336; 95% CI, 0.921-1.938). Heterogeneity among studies was not significant in any subset analysis. Conclusions: Adding DBT to FFDM enabled detection of early invasive breast cancer that might have been missed with FFDM alone. Knowing which cancer characteristic DBT detects may allow it to play a complementary role in predicting long-term patient outcomes and facilitate treatment planning.
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Digital breast tomosynthesis (DBT) is emerging as the new standard of care for breast cancer screening based on improved cancer detection coupled with reductions in recall compared to screening with digital mammography (DM) alone. However, many prior studies lack follow-up data to assess false negatives examinations. The purpose of this study is to assess if DBT is associated with improved screening outcomes based on follow-up data from tumor registries or pathology. Retrospective analysis of prospective cohort data from three research centers performing DBT screening in the PROSPR consortium from 2011 to 2014 was performed. Recall and biopsy rates were assessed from 198,881 women age 40–74 years undergoing screening (142,883 DM and 55,998 DBT examinations). Cancer, cancer detection, and false negative rates and positive predictive values were assessed on examinations with one year of follow-up. Logistic regression was used to compare DBT to DM adjusting for research center, age, prior breast imaging, and breast density. There was a reduction in recall with DBT compared to DM (8.7 vs. 10.4 %, p < 0.0001), with adjusted OR = 0.68 (95 % CI = 0.65–0.71). DBT demonstrated a statistically significant increase in cancer detection over DM (5.9 vs. 4.4/1000 screened, adjusted OR = 1.45, 95 % CI = 1.12–1.88), an improvement in PPV1 (6.4 % for DBT vs. 4.1 % for DM, adjusted OR = 2.02, 95 % CI = 1.54–2.65), and no significant difference in false negative rates for DBT compared to DM (0.46 vs. 0.60/1000 screened, p = 0.347). Our data support implementation of DBT screening based on increased cancer detection, reduced recall, and no difference in false negative screening examinations.
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Objective: Baseline mammography studies have significantly higher recall rates than mammography studies with available comparison examinations. Digital breast tomosynthesis reduces recalls when compared with digital mammographic screening alone, but many sites operate in a hybrid environment. To maximize the effect of screening digital breast tomosynthesis with limited resources, choosing which patient populations will benefit most is critical. This study evaluates digital breast tomosynthesis in the baseline screening population. Materials and methods: Outcomes were compared for 10,728 women who underwent digital mammography screening, including 1204 (11.2%) baseline studies, and 15,571 women who underwent digital breast tomosynthesis screening, including 1859 (11.9%) baseline studies. Recall rates, cancer detection rates, and positive predictive values were calculated. Logistic regression estimated the odds ratios of recall for digital mammography versus digital breast tomosynthesis for patients undergoing baseline screening and previously screened patients, adjusted for age, race, and breast density. Results: In the baseline subgroup, recall rates for digital mammography and digital breast tomosynthesis screening were 20.5% and 16.0%, respectively (p = 0.002); digital breast tomosynthesis screening in the baseline subgroup resulted in a 22% reduction in recall compared with digital mammography, or 45 fewer patients recalled per 1000 patients screened. Digital breast tomosynthesis screening in the previously screened patients resulted in recall reduction of 14.3% (p < 0.001; p for interaction = 0.21). The recall rate reduction for baseline screening was especially pronounced in women younger than 50 years (p = 0.005). DBT implementation resulted in an increase in cancer detection in the baseline subgroup of 40.5% versus an increase in the previously screened subgroup of 17.4%. DBT implementation resulted in an increase in PPV1 in the baseline subgroup of 85% versus 35.3% in the previously screened subgroup, although the p-interaction was not significant. Conclusion: If resources are limited, women younger than 50 years who are undergoing baseline screening or do not have prior available mammograms may benefit more from digital breast tomosynthesis than from digital mammography alone.
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Background Early data on breast cancer screening utilizing digital breast tomosynthesis (DBT) combined with digital mammography (DM) have shown improvements in false-positive and false-negative screening rates compared with DM alone. However, these trials were performed at sites where conventional mammographic screening was concurrently performed, possibly leading to selection biases or with complex, multireader algorithms not reflecting general clinical practice. Our study reports the impact on screening outcomes for DBT screening implemented in an entire clinic population.
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IMPORTANCE Mammography plays a key role in early breast cancer detection. Single-institution studies have shown that adding tomosynthesis to mammography increases cancer detection and reduces false-positive results. OBJECTIVE To determine if mammography combined with tomosynthesis is associated with better performance of breast screening programs in the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of screening performance metrics from 13 academic and nonacademic breast centers using mixed models adjusting for site as a random effect. EXPOSURES Period 1: digital mammography screening examinations 1 year before tomosynthesis implementation (start dates ranged from March 2010 to October 2011 through the date of tomosynthesis implementation); period 2: digital mammography plus tomosynthesis examinations from initiation of tomosynthesis screening (March 2011 to October 2012) through December 31, 2012. MAIN OUTCOMES AND MEASURES Recall rate for additional imaging, cancer detection rate, and positive predictive values for recall and for biopsy. RESULTS A total of 454 850 examinations (n=281 187 digital mammography; n=173 663 digital mammography + tomosynthesis) were evaluated. With digital mammography, 29 726 patients were recalled and 5056 biopsies resulted in cancer diagnosis in 1207 patients (n=815 invasive; n=392 in situ). With digital mammography + tomosynthesis, 15 541 patients were recalled and 3285 biopsies resulted in cancer diagnosis in 950 patients (n=707 invasive; n=243 in situ). Model-adjusted rates per 1000 screens were as follows: for recall rate, 107 (95%CI, 89-124) with digital mammography vs 91 (95%CI, 73-108) with digital mammography + tomosynthesis; difference, –16 (95%CI, –18 to –14; P < .001); for biopsies, 18.1 (95%CI, 15.4-20.8) with digital mammography vs 19.3 (95%CI, 16.6-22.1) with digital mammography + tomosynthesis; difference, 1.3 (95%CI, 0.4-2.1; P = .004); for cancer detection, 4.2 (95%CI, 3.8-4.7) with digital mammography vs 5.4 (95%CI, 4.9-6.0) with digital mammography + tomosynthesis; difference, 1.2 (95%CI, 0.8-1.6; P < .001); and for invasive cancer detection, 2.9 (95%CI, 2.5-3.2) with digital mammography vs 4.1 (95%CI, 3.7-4.5) with digital mammography + tomosynthesis; difference, 1.2 (95%CI, 0.8-1.6; P < .001). The in situ cancer detection rate was 1.4 (95%CI, 1.2-1.6) per 1000 screens with both methods. Adding tomosynthesis was associated with an increase in the positive predictive value for recall from 4.3%to 6.4%(difference, 2.1%; 95%CI, 1.7%-2.5%; P < .001) and for biopsy from 24.2%to 29.2%(difference, 5.0%; 95%CI, 3.0%-7.0%; P < .001). CONCLUSIONS AND RELEVANCE Addition of tomosynthesis to digital mammographywas associated with a decrease in recall rate and an increase in cancer detection rate. Further studies are needed to assess the relationship to clinical outcomes. JAMA. 2014;311(24):2499-2507. doi:10.1001/jama.2014.6095
Article
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Purpose: To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis in a large prospective screening trial. Materials and methods: A prospective, reader- and modality-balanced screening study of participants undergoing combined mammography plus tomosynthesis, the results of which were read independently by four different radiologists, is under way. The study was approved by a regional ethics committee, and all participants provided written informed consent. The authors performed a preplanned interim analysis of results from 12,631 examinations interpreted by using mammography alone and mammography plus tomosynthesis from November 22, 2010, to December 31, 2011. Analyses were based on marginal log-linear models for binary data, accounting for correlated interpretations and adjusting for reader-specific performance levels by using a two-sided significance level of .0294. Results: Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (27% increase, adjusted for reader; P = .001). False-positive rates before arbitration were 61.1 per 1000 examinations with mammography alone and 53.1 per 1000 examinations with mammography plus tomosynthesis (15% decrease, adjusted for reader; P < .001). After arbitration, positive predictive values for recalled patients with cancers verified later were comparable (29.1% and 28.5%, respectively, with mammography alone and mammography plus tomosynthesis; P = .72). Twenty-five additional invasive cancers were detected with mammography plus tomosynthesis (40% increase, adjusted for reader; P < .001). The mean interpretation time was 45 seconds for mammography alone and 91 seconds for mammography plus tomosynthesis (P < .001). Conclusion: The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Clinical trial registration no. NCT01248546.
Article
Background: Tomosynthesis approximates a 3D mammogram of the breast, reducing parenchymal overlap that masks cancers or creates false "lesions" on 2D mammography, and potentially enabling more accurate detection of breast cancer. We compared breast cancer screening detection and recall in asymptomatic women for tomosynthesis vs 2D mammography. Methods: A systematic review and random effects meta-analysis were undertaken. Electronic databases (2009-July 2017) were searched for studies comparing tomosynthesis and 2D mammography in asymptomatic women who attended population breast cancer screening and reporting cancer detection rate (CDR) and recall rate. All statistical tests were two-sided. Results: Seventeen studies (1 009 790 participants) were included from 413 citations. The pooled incremental CDR for tomosynthesis was 1.6 cancers per 1000 screens (95% confidence interval [CI] = 1.1 to 2.0, P < .001, I2 = 36.9%). Incremental CDR was statistically significantly higher for European/Scandinavian studies, all using a "paired" design where women had both tests (2.4 per 1000 screens, 95% CI = 1.9 to 2.9, P < .001, I2 = 0.0%) compared with US ("unpaired") studies (1.1 per 1000 screens, 95% CI = 0.8 to 1.5, P < .001, I2 = 0.0%; P < .001 between strata). The recall rate for tomosynthesis was statistically significantly lower than for 2D mammography (pooled absolute reduction = -2.2%, 95% CI = -3.0 to -1.4, P < .001, I2 = 98.2%). Stratified analyses showed a decrease in US studies (pooled difference in recall rate = -2.9%, 95% CI = -3.5 to -2.4, P < .001, I2 = 92.9%) but not European/Scandinavian studies (0.5% increase in recall, 95% CI = -0.1 to 1.2, P = .12, I2 = 93.5%; P < .001 between strata). Results were similar in sensitivity analyses excluding studies with overlapping cohorts. Conclusions: Tomosynthesis improves CDR and reduces recall; however, effects are dependent on screening setting, with greater improvement in CDR in European/Scandinavian studies (biennial screening) and reduction in recall in US studies with high baseline recall.
Article
Approximately 15% of breast cancers are diagnosed after the patient undergoes screening mammography with negative results and before the next recommended screening examination.¹ These interval cancers (cases of cancer diagnosed during the interval between examinations) include both cancers that were present during screening mammography but were missed on examination and rapidly growing cancers that present symptomatically and tend to have a poorer prognosis than cancers detected during screening.¹⁻³ Identifying women who are at high risk of breast cancer with a poor prognosis despite regular screening mammography could enable targeted supplemental screening for women for whom screening mammography may not be sufficient. This study describes the incidence of and risk factors associated with breast cancer with a poor prognosis after screening mammography with negative findings.
Article
Background & methods: The prospective 'screening with tomosynthesis or standard mammography' (STORM) trial recruited women participating in biennial breast screening in Italy (2011-2012), and compared sequential screen-readings based on 2D-mammography alone or based on tomosynthesis (integrated 2D/3D-mammography). The STORM trial showed that tomosynthesis screen-reading significantly increased breast cancer detection compared to 2D-mammography alone. The present study completes reporting of the trial by examining interval breast cancers ascertained at two year follow-up. Results: 9 interval breast cancers were identified; the estimated interval cancer rate was 1.23/1000 screens [9/7292] (95%CI 0.56 to 2.34) or 1.24/1000 negative screens [9/7235] (95%CI 0.57 to 2.36). In concurrently screened women who attended the same screening services and received 2D-mammography, interval cancer rate was 1.60/1000 screens [40/25,058] (95% CI 1.14 to 2.17) or 1.61/1000 negative screens [40/24,922] (95% CI 1.15 to 2.18). Estimated screening sensitivity for the STORM trial was 85.5% [59/69] (95%CI 75.0%-92.8%), and that for 2D-mammography screening was 77.3% [136/176] (95%CI 70.4%-83.2%). Conclusion: Interval breast cancer rate amongst screening participants in the STORM trial was marginally lower (and screening sensitivity higher) than estimates amongst 2D-screened women; these findings should be interpreted with caution given the small number of interval cases and the sample size of the trial. Much larger screening studies, or pooled analyses, are required to examine interval cancer rates arising after breast tomosynthesis screening versus digital mammography screening.
Article
Importance Given recent advances in screening mammography and adjuvant therapy (treatment), quantifying their separate and combined effects on US breast cancer mortality reductions by molecular subtype could guide future decisions to reduce disease burden. Objective To evaluate the contributions associated with screening and treatment to breast cancer mortality reductions by molecular subtype based on estrogen-receptor (ER) and human epidermal growth factor receptor 2 (ERBB2, formerly HER2 or HER2/neu). Design, Setting, and Participants Six Cancer Intervention and Surveillance Network (CISNET) models simulated US breast cancer mortality from 2000 to 2012 using national data on plain-film and digital mammography patterns and performance, dissemination and efficacy of ER/ERBB2-specific treatment, and competing mortality. Multiple US birth cohorts were simulated. Exposures Screening mammography and treatment. Main Outcomes and Measures The models compared age-adjusted, overall, and ER/ERBB2-specific breast cancer mortality rates from 2000 to 2012 for women aged 30 to 79 years relative to the estimated mortality rate in the absence of screening and treatment (baseline rate); mortality reductions were apportioned to screening and treatment. Results In 2000, the estimated reduction in overall breast cancer mortality rate was 37% (model range, 27%-42%) relative to the estimated baseline rate in 2000 of 64 deaths (model range, 56-73) per 100 000 women: 44% (model range, 35%-60%) of this reduction was associated with screening and 56% (model range, 40%-65%) with treatment. In 2012, the estimated reduction in overall breast cancer mortality rate was 49% (model range, 39%-58%) relative to the estimated baseline rate in 2012 of 63 deaths (model range, 54-73) per 100 000 women: 37% (model range, 26%-51%) of this reduction was associated with screening and 63% (model range, 49%-74%) with treatment. Of the 63% associated with treatment, 31% (model range, 22%-37%) was associated with chemotherapy, 27% (model range, 18%-36%) with hormone therapy, and 4% (model range, 1%-6%) with trastuzumab. The estimated relative contributions associated with screening vs treatment varied by molecular subtype: for ER+/ERBB2−, 36% (model range, 24%-50%) vs 64% (model range, 50%-76%); for ER+/ERBB2+, 31% (model range, 23%-41%) vs 69% (model range, 59%-77%); for ER−/ERBB2+, 40% (model range, 34%-47%) vs 60% (model range, 53%-66%); and for ER−/ERBB2−, 48% (model range, 38%-57%) vs 52% (model range, 44%-62%). Conclusions and Relevance In this simulation modeling study that projected trends in breast cancer mortality rates among US women, decreases in overall breast cancer mortality from 2000 to 2012 were associated with advances in screening and in adjuvant therapy, although the associations varied by breast cancer molecular subtype.
Article
Purpose To determine whether the rates and tumor characteristics of screening-detected and interval cancers differ for two-dimensional digital mammography (DM) versus digital breast tomosynthesis (DBT) mammography. Materials and Methods Consecutive screening mammograms from January 2009 to February 2011 (DM group, before DBT integration) and from January 2013 to February 2015 (DBT group, after complete DBT integration) were reviewed. Cancers were considered screening detected if diagnosed within 365 days of a positive screening examination and interval if diagnosed within 365 days of a negative screening examination. Z tests were used to compare cancers on DM versus DBT examinations. Results A total of 948 breast cancers were diagnosed after 78 385 DM and 76 896 DBT examinations. Although the overall rate of screening-detected cancers was similar with DM and DBT (5.0 vs 5.0 per 1000 examinations, P = .98), a higher proportion of screening-detected cancers were invasive rather than in situ with DBT (74.2% [287 of 387] vs 66.0% [260 of 394], P = .01). There were no significant differences in tumor characteristics, including size at pathologic examination, grade, hormone receptor status, and nodal status, between the screening-detected invasive cancers on DM versus DBT (P = .09-.99). The rate of interval cancers was similar with DM and DBT (1.1 vs 1.1 per 1000 examinations, P = .84). Compared with symptomatic interval cancers, magnetic resonance imaging-detected interval cancers were more likely to be minimal cancers. Conclusion The overall rates of screening-detected and interval cancers are similar with DM and DBT, but a higher proportion of screening-detected cancers are invasive rather than in situ with DBT. © RSNA, 2017.
Article
Objective: The purpose of this study was to analyze the clinicopathologic and immunohistochemical features of invasive breast cancers detected only with digital breast tomosynthesis (DBT), compared with those of cancers detected with both DBT and full-field digital mammography (FFDM). Materials and methods: The medical records of 261 women (108 without and 153 with symptoms) with invasive breast cancers who underwent FFDM and DBT between April 2015 and June 2016 were retrospectively reviewed. To assess detectability, all DBT and FFDM images were reviewed independently by three radiologists blinded to clinicopathologic information. The reference standard was established by an unblinded consensus review of all images. Clinicopathologic and immunohistochemical features were analyzed according to the detectability status. Results: Of the 261 cancers, 223 (85.4%) were detected with both DBT and FFDM (both-detected group). Twenty-four cancers (9.2%) not detected with FFDM (DBT-only group) were classified by DBT as a mass (58.3%), architectural distortion (33.3%), or asymmetry (8.3%). The remaining 14 cancers (5.4%) were not detected with either DBT or FFDM (both-occult group). On multivariate analysis, a dense breast parenchyma (p = 0.007), small tumor size (≤ 2 cm; p = 0.027), and luminal A-like subtype (estrogen receptor positive or progesterone receptor positive or both, human epidermal growth factor receptor 2 negative, and Ki-67 expression < 14%; p = 0.008) were significantly associated with the DBT-only group. For 108 screening-detected cancers, a dense breast parenchyma (p = 0.007) and luminal A-like subtype (p = 0.008) also maintained significance. Conclusion: The addition of DBT to FFDM in screening would aid in the detection of less-aggressive subtypes of invasive breast cancers in women with dense breasts.
Article
To compare the pathology and histologic grading of breast cancers detected with digital breast tomosynthesis to those found with conventional digital mammography. The institutional review board approved this study. A database search for all breast cancers diagnosed from June 2012 through December 2013 was performed. Imaging records for these cancers were reviewed and patients who had screening mammography with tomosynthesis as their initial examination were selected. Five dedicated breast imaging radiologists reviewed each of these screening mammograms to determine whether the cancer was visible on conventional digital mammography or whether tomosynthesis was needed to identify the cancer. A cancer was considered mammographically occult if all five radiologists agreed that the cancer could not be seen on conventional digital mammography. The size, pathology and histologic grading for all diagnosed breast cancers were then reviewed. The Mann–Whitney U and Fisher exact tests were utilized to determine any association between imaging findings and cancer size, pathologic type and histologic grade. Sixty-five cancers in 63 patients were identified. Ten of these cancers were considered occult on conventional digital mammography and detected with the addition of tomosynthesis. These mammographically occult cancers were significantly associated with Nottingham grade 1 histologic pathology (p = 0.02), were smaller (median size: 6 mm versus 10 mm, p = 0.07) and none demonstrated axillary nodal metastases. Breast cancers identified through the addition of tomosynthesis are associated with Nottingham grade 1 histologic pathology and prognostically more favorable than cancers identified with conventional digital mammography alone.
Article
Importance Breast cancer screening with digital breast tomosynthesis (DBT) combined with digital mammography (DM) decreases false-positive examinations and increases cancer detection compared with screening with DM alone. However, the longitudinal performance of DBT screening is unknown.Objectives To determine whether the improved outcomes observed after initial implementation of DBT screening are sustainable over time at a population level and to evaluate the effect of more than 1 DBT screening at the individual level.Design, Setting, and Participants Retrospective analysis of screening mammography metrics was performed for all patients presenting for screening mammography in an urban, academic breast center during 4 consecutive years (DM, year 0; DBT, years, 1-3). The study was conducted from September 1, 2010, to September 30, 2014 (excluding September 2011, which was the transition period from DM to DBT), for a total of 44 468 screening events attributable to a total of 23 958 unique women. Differences in screening outcomes between each DBT year and the DM year, as well as between groups of women with only 1, 2, or 3 DBT screenings, were assessed, and the odds of recall adjusted for age, race/ethnicity, breast density, and prior mammograms were estimated. Data analysis was performed between February 16 and October 26, 2015.Exposure Digital mammography screening supplemented with DBT.Main Outcomes and Measures Recall rates, cancer cases per recalled patients, and biopsy and interval cancer rates were determined.Results Screening outcome metrics were evaluated for a total of 44 468 examinations attributable to 23 958 unique women (mean [SD] age, 56.8 [11.0] years) over a 4-year period: year 0 cohort (DM0), 10 728 women; year 1 cohort (DBT1), 11 007; year 2 cohort (DBT2), 11 157; and year 3 cohort (DBT3), 11 576. Recall rates rose slightly for years 1 to 3 of DBT (88, 90, and 92 per 1000 screened, respectively) but remained significantly reduced compared with the DM0 rate of 104 per 1000 screened. Reported as odds ratios (95% CIs), the findings were DM vs DBT1, 0.83 (0.76-0.91, P < .001); DM vs DBT2, 0.85 (0.78-0.93, P < .001); and DM vs DBT3, 0.87 (0.80-0.95, P = .003). The cancer cases per recalled patients continued to rise from DM0 rate of 4.4% to 6.2% (P = .06), 6.5% (P = .03), and 6.7% (P = .02) for years 1 to 3 of DBT, respectively. Outcomes assessed for the most recent screening for individual women undergoing only 1, 2, or 3 DBT screenings during the study period demonstrated decreasing recall rates of 130, 78, and 59 per 1000 screened, respectively (P < .001). Interval cancer rates, determined using available follow-up data, decreased from 0.7 per 100 women screened with the use of DM to 0.5 per 1000 screened with the use of DBT1.Conclusions and Relevance Digital breast tomosynthesis screening outcomes are sustainable, with significant recall reduction, increasing cancer cases per recalled patients, and a decline in interval cancers.
Article
Little in population health practice has received more scrutiny than mammography screening, and the relentless debate around breast cancer (BC) screening is unlikely to fade as the options of adjunct screening technologies increase. Yet none of the currently available adjunct breast imaging technologies seems as promising, or as feasible to implement on a large scale, as digital breast tomosynthesis (DBT), a pseudo–3-dimensional derivative technology of digital mammography (DM). In fact, this technology appears to be disseminating throughout the United States faster than the pace witnessed for DM in the preceding decade, with 50% of facilities in the Breast Cancer Surveillance Consortium now offering DBT.
Article
Purpose: To examine recall rates from screening mammography and the mammographic findings that caused recall in women who underwent digital breast tomosynthesis with conventional mammography (referred to as two-dimensional [ 2D two-dimensional ] with three-dimensional [ 3D three-dimensional ] imaging [ 2D two-dimensional + 3D three-dimensional ]) and in women who underwent conventional mammography alone (referred to as 2D two-dimensional ). Materials and methods: This was an institutional review board-approved, HIPAA-compliant study with waivers of informed consent. A retrospective review of 2D two-dimensional + 3D three-dimensional and 2D two-dimensional screening mammograms from August 1, 2011, to December 31, 2012, was performed. Recall rates and abnormalities that caused recall were compared by controlling for differences in patient age, breast density, and risk factors. Cancer detection rate was assessed from this time period and from 1 year before the introduction of tomosynthesis for a historic control. Results: This study included 17 955 screening mammograms; of the total, there were 8591 (47.8%) 2D two-dimensional + 3D three-dimensional screening examinations and 9364 (52.2%) 2D two-dimensional examinations. The recall rate was 7.8% (671 of 8592) for 2D two-dimensional + 3D three-dimensional and 12.3% (1154 of 9364) for 2D two-dimensional (P < .0001); the rate of recall was 36.6% lower in the 2D two-dimensional + 3D three-dimensional group than in the 2D two-dimensional group. Recall rates for the 2D two-dimensional + 3D three-dimensional group were significantly lower for patients with asymmetries, ( 2D two-dimensional + 3D three-dimensional vs 2D two-dimensional , 3.1% [267 of 8591] vs 7.4% [689 of 9364], respectively; P < .0001) and calcifications ( 2D two-dimensional + 3D three-dimensional vs 2D two-dimensional , 2.4% [205 of 8591] vs 3.2% [297 of 9364], respectively; P = .0014). For patients with masses and architectural distortion, the difference in recall rates was not significant (masses: 2D two-dimensional + 3D three-dimensional vs 2D two-dimensional , 2.5% [215 of 8591] vs 2.5% [237 of 9364], respectively; P = .90; architectural distortion: 2D two-dimensional + 3D three-dimensional vs 2D two-dimensional , 0.68% [58 of 8591] vs 0.69% [65 of 9364]; P = .88). Cancer detection was highest in the 2D two-dimensional + 3D three-dimensional group at 5.9 cancers per 1000 examinations, with 5.7 cancers per 1000 examinations in the concurrent 2D two-dimensional group, and 4.4 cancers per 1000 examinations in the historic control. Conclusion: Use of tomosynthesis ( 2D two-dimensional + 3D three-dimensional ) compared with conventional mammography ( 2D two-dimensional ) is associated with a lower recall rate of screening mammography, most often for asymmetries.
Article
Objective: Digital mammography combined with tomosynthesis is gaining clinical acceptance, but data are limited that show its impact in the clinical environment. We assessed the changes in performance measures, if any, after the introduction of tomosynthesis systems into our clinical practice. Materials and methods: In this observational study, we used verified practice- and outcome-related databases to compute and compare recall rates, biopsy rates, cancer detection rates, and positive predictive values for six radiologists who interpreted screening mammography studies without (n = 13,856) and with (n = 9499) the use of tomosynthesis. Two-sided analyses (significance declared at p < 0.05) accounting for reader variability, age of participants, and whether the examination in question was a baseline were performed. Results: For the group as a whole, the introduction and routine use of tomosynthesis resulted in significant observed changes in recall rates from 8.7% to 5.5% (p < 0.001), nonsignificant changes in biopsy rates from 15.2 to 13.5 per 1000 screenings (p = 0.59), and cancer detection rates from 4.0 to 5.4 per 1000 screenings (p = 0.18). The invasive cancer detection rate increased from 2.8 to 4.3 per 1000 screening examinations (p = 0.07). The positive predictive value for recalls increased from 4.7% to 10.1% (p < 0.001). Conclusion: The introduction of breast tomosynthesis into our practice was associated with a significant reduction in recall rates and a simultaneous increase in breast cancer detection rates.
Article
Background: Digital breast tomosynthesis with 3D images might overcome some of the limitations of conventional 2D mammography for detection of breast cancer. We investigated the effect of integrated 2D and 3D mammography in population breast-cancer screening. Methods: Screening with Tomosynthesis OR standard Mammography (STORM) was a prospective comparative study. We recruited asymptomatic women aged 48 years or older who attended population-based breast-cancer screening through the Trento and Verona screening services (Italy) from August, 2011, to June, 2012. We did screen-reading in two sequential phases-2D only and integrated 2D and 3D mammography-yielding paired data for each screen. Standard double-reading by breast radiologists determined whether to recall the participant based on positive mammography at either screen read. Outcomes were measured from final assessment or excision histology. Primary outcome measures were the number of detected cancers, the number of detected cancers per 1000 screens, the number and proportion of false positive recalls, and incremental cancer detection attributable to integrated 2D and 3D mammography. We compared paired binary data with McNemar's test. Findings: 7292 women were screened (median age 58 years [IQR 54-63]). We detected 59 breast cancers (including 52 invasive cancers) in 57 women. Both 2D and integrated 2D and 3D screening detected 39 cancers. We detected 20 cancers with integrated 2D and 3D only versus none with 2D screening only (p<0.0001). Cancer detection rates were 5.3 cancers per 1000 screens (95% CI 3.8-7.3) for 2D only, and 8.1 cancers per 1000 screens (6.2-10.4) for integrated 2D and 3D screening. The incremental cancer detection rate attributable to integrated 2D and 3D mammography was 2.7 cancers per 1000 screens (1.7-4.2). 395 screens (5.5%; 95% CI 5.0-6.0) resulted in false positive recalls: 181 at both screen reads, and 141 with 2D only versus 73 with integrated 2D and 3D screening (p<0.0001). We estimated that conditional recall (positive integrated 2D and 3D mammography as a condition to recall) could have reduced false positive recalls by 17.2% (95% CI 13.6-21.3) without missing any of the cancers detected in the study population. Interpretation: Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. Randomised controlled trials are needed to compare integrated 2D and 3D mammography with 2D mammography for breast cancer screening. Funding: National Breast Cancer Foundation, Australia; National Health and Medical Research Council, Australia; Hologic, USA; Technologic, Italy.
Digital breast tomosynthesis: a brave new world of mammography screening
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Association of screening and treatment with breast cancer mortality by molecular subtype in US women
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Kim JY, Kang HJ, Shin JK, et al. Biologic profiles of invasive breast cancers detected only with digital breast tomosynthesis. AJR Am J Roentgenol. 2017; 209(6):1411-1418. doi:10.2214/AJR.17.18195 17. Plevritis SK, Munoz D, Kurian AW, et al. Association of screening and treatment with breast cancer mortality by molecular subtype in US women, 2000-2012. JAMA. 2018;319(2):154-164. doi:10.1001/jama.2017.19130
BI-RADS: mammography
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D'Orsi CJ, Bassett LW, Berg WA, et al. BI-RADS: mammography. In: D'Orsi CJ, Mendelson EB, Ikeda DM, et al, eds. Breast Imaging Reporting and Data System: ACR BI-RADS-Breast Imaging Atlas. 4th ed. Reston, VA: American College of Radiology; 2003.
Breast cancer with a poor prognosis diagnosed after screening mammography with negative results
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