Relative timing of mammography and MRI for breast cancer screening: Impact on performance evaluation.

OBJECTIVE: Mammography and MRI screening typically occur in combination or in alternating sequence. We compared multimodality screening performance accounting for the relative timing of mammography and MRI and overlapping follow-up periods. METHODS: We identified 8,260 screening mammograms performed 2005-2017 in the Breast Cancer Surveillance Consortium, paired with screening MRIs within +/- 90 days (combined screening) or 91-270 days (alternating screening). Performance for combined screening [cancer detection rate (CDR) per 1000 examinations and sensitivity] was calculated with one-year follow-up for each modality, and with a single follow-up period treating the two tests as a single test. Alternating screening performance was calculated with one-year follow-up for each modality and also with follow-up ending at the next screen if within one year (truncated follow-up). RESULTS: For 3,810 combined screening pairs, CDR per 1000 screens was 6.8 (95%CI: 4.6-10.0) for mammography and 12.3 (95%CI: 9.3-16.4) for MRI as separate tests compared to 13.1 (95%CI: 10.0-17.3) as a single combined test. Sensitivity of each test was 48.1% (35.0%-61.5%) for mammography and 79.7% (95%CI: 67.7-88.0%) for MRI compared to 96.2% (95%CI: 85.9-99.0%) for combined screening. For 4,450 alternating screening pairs, mammography CDR per 1000 screens changed from 3.6 (95%CI: 2.2-5.9) to zero with truncated follow-up; sensitivity was incalculable (denominator=0). MRI CDR per 1000 screens changed from 12.1 (95%CI 9.3-15.8) to 11.7 (95%CI: 8.9-15.3) with truncated follow-up; sensitivity changed from 75.0% (95%CI 63.8-83.6%) to 86.7% (95%CI 75.5-93.2%). DISCUSSION: Updating auditing approaches to account for combined and alternating screening sequencing and to address outcome attribution issues arising from overlapping follow-up periods can improve the accuracy of multimodality screening performance evaluation.

Breast density knowledge and willingness to delay treatment for pre-operative breast cancer imaging among women with a personal history of breast cancer.

BACKGROUND: Following a breast cancer diagnosis, it is uncertain whether women's breast density knowledge influences their willingness to undergo pre-operative imaging to detect additional cancer in their breasts. We evaluated women's breast density knowledge and their willingness to delay treatment for pre-operative testing. METHODS: We surveyed women identified in the Breast Cancer Surveillance Consortium aged ≥ 18 years, with first breast cancer diagnosed within the prior 6-18 months, who had at least one breast density measurement within the 5 years prior to their diagnosis. We assessed women's breast density knowledge and correlates of willingness to delay treatment for 6 or more weeks for pre-operative imaging via logistic regression. RESULTS: Survey participation was 28.3% (969/3,430). Seventy-two percent (469/647) of women with dense and 11% (34/322) with non-dense breasts correctly knew their density (p < 0.001); 69% (665/969) of all women knew dense breasts make it harder to detect cancers on a mammogram; and 29% (285/969) were willing to delay treatment ≥ 6 weeks to undergo pre-operative imaging. Willingness to delay treatment did not differ by self-reported density (OR:0.99 for non-dense vs. dense; 95%CI: 0.50-1.96). Treatment with chemotherapy was associated with less willingness to delay treatment (OR:0.67; 95%CI: 0.46-0.96). Having previously delayed breast cancer treatment more than 3 months was associated with an increased willingness to delay treatment for pre-operative imaging (OR:2.18; 95%CI: 1.26-3.77). CONCLUSIONS: Understanding of personal breast density was not associated with willingness to delay treatment 6 or more weeks for pre-operative imaging, but aspects of a woman's treatment experience were. CLINICALTRIALS: GOV : NCT02980848 registered December 2, 2016.

Characterizing the Traveling Oncology Workforce and Its Influence on Patient Travel Burden: A Claims-Based Approach.

PURPOSE: Oncology outreach is a common strategy for extending cancer care to rural patients. However, a nationwide characterization of the traveling workforce that enables this outreach is lacking, and the extent to which outreach reduces travel burden for rural patients is unknown. METHODS: This cross-sectional study analyzed a rural (nonurban) subset of a 100% fee-for-service sample of 355,139 Medicare beneficiaries with incident breast, colorectal, and lung cancers. Surgical, medical, and radiation oncologists were linked to patients using Part B claims, and traveling oncologists were identified by observing hospital service area (HSA) transition patterns. We defined oncology outreach as the provision of cancer care by a traveling oncologist outside of their primary HSA. We used hierarchical gamma regression models to examine the separate associations between patient receipt of oncology outreach and one-way patient travel times to chemotherapy, radiotherapy, and surgery. RESULTS: On average, 9,935 of 39,960 oncologists conducted annual outreach, where 57.8% traveled with low frequency (0-1 outreach visits/mo), 21.1% with medium frequency (1-3 outreach visits/mo), and 21.1% with high frequency (>3 outreach visits/mo). Oncologists provided surgery, radiotherapy, and chemotherapy to 51,715, 27,120, and 5,874 rural beneficiaries, respectively, of whom 2.5%, 6.9%, and 3.6% received oncology outreach. Rural patients who received oncology outreach traveled 16% (95% CI, 11 to 21) and 11% (95% CI, 9 to 13) less minutes to chemotherapy and radiotherapy than those who did not receive oncology outreach, corresponding to expected one-way savings of 15.9 (95% CI, 15.5 to 16.4) and 11.9 (95% CI, 11.7 to 12.2) minutes, respectively. CONCLUSION: Our study introduces a novel claims-based approach for tracking the nationwide traveling oncology workforce and supports oncology outreach as an effective means for improving rural access to cancer care.

Risk factors and health behaviors associated with loneliness among cancer survivors during the COVID-19 pandemic.

Loneliness may exacerbate poor health outcomes particularly among cancer survivors during the COVID-19 pandemic. Little is known about the risk factors of loneliness among cancer survivors. We evaluated the risk factors of loneliness in the context of COVID-19 pandemic-related prevention behaviors and lifestyle/psychosocial factors among cancer survivors. Cancer survivors (n = 1471) seen at Huntsman Cancer Institute completed a survey between August-September 2020 evaluating health behaviors, medical care, and psychosocial factors including loneliness during COVID-19 pandemic. Participants were classified into two groups: 'lonely' (sometimes, usually, or always felt lonely in past month) and 'non-lonely' (never or rarely felt lonely in past month). 33% of cancer survivors reported feeling lonely in the past month. Multivariable logistic regression showed female sex, not living with a spouse/partner, poor health status, COVID-19 pandemic-associated lifestyle factors including increased alcohol consumption and marijuana/CBD oil use, and psychosocial stressors such as disruptions in daily life, less social interaction, and higher perceived stress and financial stress were associated with feeling lonely as compared to being non-lonely (all p < 0.05). A significant proportion of participants reported loneliness, which is a serious health risk among vulnerable populations, particularly cancer survivors. Modifiable risk factors such as unhealthy lifestyle behaviors and psychosocial stress were associated with loneliness. These results highlight the need to screen for unhealthy lifestyle factors and psychosocial stressors to identify cancer survivors at increased risk of loneliness and to develop effective management strategies.

Broadband Data Forensics: Spatiotemporal Variations of the Download/Upload Speed Metric Commonly Used to Evaluate Potential Telehealth Accessibility.

Introduction: The complicated task of evaluating potential telehealth access begins with the metrics and supporting datasets that seek toevaluate the presence and durability of broadband connections in a community. Broadband download/upload speeds are one of the popular metrics used to measure potential telehealth access, which is critical to health equity. An understanding of the limitations of these measures is important for drawing conclusions about the reality of the digital divide in telehealth access. The objective of this study was to assess spatiotemporal variations in broadband download/upload speeds. Method: We analyzed a sample of data from the Speedtest Intelligence Portal provided through the Ookla for Good initiative. Results: We found that variation is inherent across the states of Vermont, New Hampshire, Louisiana, and Utah. Conclusions: The variation suggests that when single measures of download/upload speeds are used to evaluate telehealth accessibility they may be masking the true magnitude of the digital divide.

Association between a network-based physician linchpin score and cancer patient mortality: a SEER-Medicare analysis.

BACKGROUND: Patients with cancer frequently require multidisciplinary teams for optimal cancer outcomes. Network analysis can capture relationships among cancer specialists, and we developed a novel physician linchpin score to characterize "linchpin" physicians whose peers have fewer ties to other physicians of the same oncologic specialty. Our study examined whether being treated by a linchpin physician was associated with worse survival. METHODS: In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results-Medicare data for patients diagnosed with stage I to III non-small cell lung cancer or colorectal cancer (CRC) in 2016-2017. We assembled patient-sharing networks and calculated linchpin scores for medical oncologists, radiation oncologists, and surgeons. Physicians were considered linchpins if their linchpin score was within the top 15% for their specialty. We used Cox proportional hazards models to examine associations between being treated by a linchpin physician and survival, with a 2-year follow-up period. RESULTS: The study cohort included 10 081 patients with non-small cell lung cancer and 9036 patients with CRC. Patients with lung cancer treated by a linchpin radiation oncologist had a 17% (95% confidence interval = 1.04 to 1.32) greater hazard of mortality, and similar trends were observed for linchpin medical oncologists. Patients with CRC treated by a linchpin surgeon had a 22% (95% confidence interval = 1.03 to 1.43) greater hazard of mortality. CONCLUSIONS: In an analysis of Medicare beneficiaries with nonmetastatic lung cancer or CRC, those treated by linchpin physicians often experienced worse survival. Efforts to improve outcomes can use network analysis to identify areas with reduced access to multidisciplinary specialists.

Development of the Rural Perception Scale (RPS-18).

BACKGROUND: People living in rural areas often experience limited access to health resources, slow knowledge diffusion, and geographical isolation, and tend to be at higher risk for poor physical and mental health outcomes compared with nonrural populations. It is unclear, yet, how the concept of "rural" shapes observed differences from nonrural populations. We aim to develop a psychometrically sound scale to assess key dimensions that constitute individual-level perceived rurality. METHODS: We first conducted a broad literature review to identify a priori concepts related to rurality and adapted survey items measuring relevant constructs, such as loneliness, attitudes toward people living in rural areas, and perceived social membership. We used these conceptual constructs and measures to develop a survey questionnaire focused on rural perceptions. We recruit residents in 3 rural states: Kentucky, New Hampshire, and Vermont. Using the explorative factor analysis and second-order measurement model in the structural equation model framework, we developed a rural perception scale consisting of 18 items. RESULTS: We recruited 1,384 participants (n = 686 from KY; n = 698 from NH/VT) using Amazon Mechanical Turk (n = 897, 64.8%) and social media paid ads (n = 487, 35.2%). The average age of participants was 41 years old (SD = 15); 54.7% of respondents had less than college graduate education, and 94.2% reported their race as non-Hispanic White. Majority of the participants were from Rural Urban Commuting Area (RUCA)-designated urban areas (n = 798, 57.7%), followed by RUCA-designated large rural areas (257, 18.6%), RUCA-designated rural areas (n = 174, 12.6%) and RUCA-designated isolated areas (n = 133, 9.6%). Our final model revealed 4 latent constructs: "belonging" (Cronbach's α = 0.896), "attitudes toward rural life" (Cronbach's α = 0.807), "loneliness" (Cronbach's α = 0.898), and "community social ties to people in their community" (Cronbach's α = 0.846). CONCLUSIONS: We identified 4 subfactors of the umbrella concept of rurality that explain how people in rural regions may perceive being in rural environments and having rural lifestyles.

Self-sampling tools to increase cancer screening among underserved patients: a pilot randomized controlled trial.

BACKGROUND: Screening can reduce cancer mortality, but uptake is suboptimal and characterized by disparities. Home-based self-sampling can facilitate screening for colorectal cancer (with stool tests, eg, fecal immunochemical tests) and for cervical cancer (with self-collected human papillomavirus tests), especially among patients who face barriers to accessing health care. Additional data are needed on feasibility and potential effects of self-sampling tools for cancer screening among underserved patients. METHODS: We conducted a pilot randomized controlled trial with patients (female, ages 50-65 years, out of date with colorectal and cervical cancer screening) recruited from federally qualified health centers in rural and racially segregated counties in Pennsylvania. Participants in the standard-of-care arm (n = 24) received screening reminder letters. Participants in the self-sampling arm (n = 24) received self-sampling tools for fecal immunochemical tests and human papillomavirus testing. We assessed uptake of screening (10-week follow-up), self-sampling screening outcomes, and psychosocial variables. Analyses used Fisher exact tests to assess the effect of study arm on outcomes. RESULTS: Cancer screening was higher in the self-sampling arm than the standard-of-care arm (colorectal: 75% vs 13%, respectively, odds ratio = 31.32, 95% confidence interval = 5.20 to 289.33; cervical: 79% vs 8%, odds ratio = 72.03, 95% confidence interval = 9.15 to 1141.41). Among participants who returned the self-sampling tools, the prevalence of abnormal findings was 24% for colorectal and 18% for cervical cancer screening. Cancer screening knowledge was positively associated with uptake (P < .05). CONCLUSIONS: Self-sampling tools can increase colorectal and cervical cancer screening among unscreened, underserved patients. Increasing the use of self-sampling tools can improve primary care and cancer detection among underserved patients. CLINICAL TRIALS REGISTRATION NUMBER: STUDY00015480.

Supplemental magnetic resonance imaging plus mammography compared with magnetic resonance imaging or mammography by extent of breast density.

BACKGROUND: Examining screening outcomes by breast density for breast magnetic resonance imaging (MRI) with or without mammography could inform discussions about supplemental MRI in women with dense breasts. METHODS: We evaluated 52 237 women aged 40-79 years who underwent 2611 screening MRIs alone and 6518 supplemental MRI plus mammography pairs propensity score-matched to 65 810 screening mammograms. Rates per 1000 examinations of interval, advanced, and screen-detected early stage invasive cancers and false-positive recall and biopsy recommendation were estimated by breast density (nondense = almost entirely fatty or scattered fibroglandular densities; dense = heterogeneously/extremely dense) adjusting for registry, examination year, age, race and ethnicity, family history of breast cancer, and prior breast biopsy. RESULTS: Screen-detected early stage cancer rates were statistically higher for MRI plus mammography vs mammography for nondense (9.3 vs 2.9; difference = 6.4, 95% confidence interval [CI] = 2.5 to 10.3) and dense (7.5 vs 3.5; difference = 4.0, 95% CI = 1.4 to 6.7) breasts and for MRI vs MRI plus mammography for dense breasts (19.2 vs 7.5; difference = 11.7, 95% CI = 4.6 to 18.8). Interval rates were not statistically different for MRI plus mammography vs mammography for nondense (0.8 vs 0.5; difference = 0.4, 95% CI = -0.8 to 1.6) or dense breasts (1.5 vs 1.4; difference = 0.0, 95% CI = -1.2 to 1.3), nor were advanced cancer rates. Interval rates were not statistically different for MRI vs MRI plus mammography for nondense (2.6 vs 0.8; difference = 1.8 (95% CI = -2.0 to 5.5) or dense breasts (0.6 vs 1.5; difference = -0.9, 95% CI = -2.5 to 0.7), nor were advanced cancer rates. False-positive recall and biopsy recommendation rates were statistically higher for MRI groups than mammography alone. CONCLUSION: MRI screening with or without mammography increased rates of screen-detected early stage cancer and false-positives for women with dense breasts without a concomitant decrease in advanced or interval cancers.

Screening Beyond the Evidence: Patterns of Age and Comorbidity for Breast, Cervical, and Colorectal Cancer Screening.

BACKGROUND: Little evidence exists to guide continuation of screening beyond the recommended ages of national guidelines for breast, cervical, and colorectal cancers, although increasing age and comorbidity burden is likely to reduce the screening benefit of lower mortality. OBJECTIVE: Characterize screening after recommended stopping ages, by age and comorbidities in a large, diverse sample. DESIGN: Serial cross-sectional. PARTICIPANTS: All individuals in the PROSPR-I consortium cohorts from 75 to 89 years of age for breast cancer screening, 66-89 years of age for cervical cancer screening, and 76-89 years of age for colorectal cancer screening from 2011 to 2013. The lower age thresholds were based on the guidelines for each respective cancer type. MAIN MEASURES: Proportion of annual screening by cancer type in relation to age and Charlson comorbidity score and median years of screening past guideline age. We estimated the likelihood of screening past the guideline-based age as a function of age and comorbidity using logistic regression. KEY RESULTS: The study cohorts included individuals screening for breast (n = 33,475); cervical (n = 459,318); and colorectal (n = 556,356) cancers. In the year following aging out, approximately 30% of the population was screened for breast cancer, 2% of the population was screened for cervical, and almost 5% for colorectal cancer. The median number of years screened past the guideline-based recommendation was 5, 3, and 4 for breast, cervical, and colorectal cancer, respectively. Of those screening > 10 years past the guideline-based age,15%, 46%, and 25% had ≥ 3 comorbidities respectively. Colorectal cancer screening had the smallest decline in the likelihood of screening beyond the age-based recommendation. CONCLUSIONS: The odds of screening past guideline-based age decreased with comorbidity burden for breast and cervical cancer screening but not for colorectal. These findings suggest the need to evaluate shared decision tools to help patients understand whether screening is appropriate and to generate more evidence in older populations.

From active treatment to surveillance: how the barriers and facilitators of implementing survivorship care planning could be an opportunity for telehealth in oncology care for rural patients.

PURPOSE: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery, and the opportunity for telehealth in cancer survivorship is examined. METHODS: We conducted a mixed-methods study in Vermont and New Hampshire to characterize perceptions of rural cancer providers and survivors regarding survivorship transitions in care, consisting of (a) key informant interviews with primary care and oncology clinicians, (b) a broader survey of clinicians, and (c) surveys and focus group discussions with cancer survivors. In these interactions, we also explored the use of a shared telehealth survivorship care planning appointment between oncology clinicians, primary care clinicians, and survivors. RESULTS: Results from surveys and interviews clustered around several themes, namely (1) infrequent care transitioning back to primary care, (2) lack of mental health services, (3) lack of side effect education, (4) low perceived utility of survivorship care plans, (5) clinicians exclusively communicate using the EMR and finding it imperfect, and (6) clinicians and survivors reported conflicting perceptions regarding survivors' access to telehealth options. CONCLUSIONS: Our results suggest that telehealth has the potential to augment the delivery of survivorship care planning; however, key technical and logistical concerns need to be addressed, particularly enhanced coordination across clinician scheduling and ensuring payment parity for various telehealth implementation strategies. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery. There is an opportunity for the application of telehealth for supportive care in survivorship care planning, which should be a focus of further research.

Digital mammography and digital breast tomosynthesis for detecting invasive lobular and ductal carcinoma.

PURPOSE: Invasive lobular carcinoma (ILC) is a distinct histological subtype of breast cancer that can make early detection with mammography challenging. We compared imaging performance of digital breast tomosynthesis (DBT) to digital mammography (DM) for diagnoses of ILC, invasive ductal carcinoma (IDC), and invasive mixed carcinoma (IMC) in a screening population. METHODS: We included screening exams (DM; n = 1,715,249 or DBT; n = 414,793) from 2011 to 2018 among 839,801 women in the Breast Cancer Surveillance Consortium. Examinations were followed for one year to ascertain incident ILC, IDC, or IMC. We measured cancer detection rate (CDR) and interval invasive cancer rate/1000 screening examinations for each histological subtype and stratified by breast density and modality. We calculated relative risk (RR) for DM vs. DBT using log-binomial models to adjust for the propensity of receiving DBT vs. DM. RESULTS: Unadjusted CDR per 1000 mammograms of ILC overall was 0.33 (95%CI: 0.30-0.36) for DM; 0.45 (95%CI: 0.39-0.52) for DBT, and for women with dense breasts- 0.33 (95%CI: 0.29-0.37) for DM and 0.54 (95%CI: 0.43-0.66) for DBT. Similar results were noted for IDC and IMC. Adjusted models showed a significantly increased RR for cancer detection with DBT compared to DM among women with dense breasts for all three histologies (RR; 95%CI: ILC 1.53; 1.09-2.14, IDC 1.21; 1.02-1.44, IMC 1.76; 1.30-2.38), but no significant increase among women with non-dense breasts. CONCLUSION: DBT was associated with higher CDR for ILC, IDC, and IMC for women with dense breasts. Early detection of ILC with DBT may improve outcomes for this distinct clinical entity.

From active treatment to surveillance: How the barriers and facilitators of implementing survivorship care planning could be an opportunity for telehealth in oncology care for rural patients.

Purpose: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery and the opportunity for telehealth in cancer survivorship is examined. Methods: We conducted a mixed-methods study in Vermont and New Hampshire to characterize perceptions of rural cancer providers and survivors regarding survivorship transitions in care, consisting of: a) key informant interviews with primary care and oncology clinicians, b) a broader survey of clinicians, and c) surveys and focus group discussions with cancer survivors. In these interactions, we also explored the use of a shared telehealth survivorship care planning appointment between oncology clinicians, primary care clinicians, and survivors. Results: Results from surveys and interviews clustered around several themes, namely: 1) infrequent care transitioning back to primary care; 2) lack of mental health services; 3) lack of side effect education; 4) low perceived utility of survivorship care plans; 5) clinicians exclusively communicate using the EMR and finding it imperfect; and 6) clinicians and survivors reported conflicting perceptions regarding survivors' access to telehealth options. Conclusions: Our results suggest that telehealth has potential to augment the delivery of survivorship care planning; however, key technical and logistical concerns need to be addressed, particularly enhanced coordination across clinician scheduling and ensuring payment parity for various telehealth implementation strategies. Implications for Cancer Survivors: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery. There is an opportunity for the application of telehealth for supportive care in survivorship care planning, which should be a focus of further research.

Impact of Surveillance Mammography Intervals Less Than One Year on Performance Measures in Women With a Personal History of Breast Cancer.

OBJECTIVE: When multiple surveillance mammograms are performed within an annual interval, the current guidance for one-year follow-up to determine breast cancer status results in shared follow-up periods in which a single breast cancer diagnosis can be attributed to multiple preceding examinations, posing a challenge for standardized performance assessment. We assessed the impact of using follow-up periods that eliminate the artifactual inflation of second breast cancer diagnoses. MATERIALS AND METHODS: We evaluated surveillance mammograms from 2007-2016 in women with treated breast cancer linked with tumor registry and pathology outcomes. Second breast cancers included ductal carcinoma in situ or invasive breast cancer diagnosed during one-year follow-up. The cancer detection rate, interval cancer rate, sensitivity, and specificity were compared using different follow-up periods: standard one-year follow-up per the American College of Radiology versus follow-up that was shortened at the next surveillance mammogram if less than one year (truncated follow-up). Performance measures were calculated overall and by indication (screening, evaluation for breast problem, and short interval follow-up). RESULTS: Of 117971 surveillance mammograms, 20% (n = 23533) were followed by another surveillance mammogram within one year. Standard follow-up identified 1597 mammograms that were associated with second breast cancers. With truncated follow-up, the breast cancer status of 179 mammograms (11.2%) was revised, resulting in 1418 mammograms associated with unique second breast cancers. The interval cancer rate decreased with truncated versus standard follow-up (3.6 versus 4.9 per 1000 mammograms, respectively), with a difference (95% confidence interval [CI]) of -1.3 (-1.6, -1.1). The overall sensitivity increased to 70.4% from 63.7%, for the truncated versus standard follow-up, with a difference (95% CI) of 6.6% (5.6%, 7.7%). The specificity remained stable at 98.1%. CONCLUSION: Truncated follow-up, if less than one year to the next surveillance mammogram, enabled second breast cancers to be associated with a single preceding mammogram and resulted in more accurate estimates of diagnostic performance for national benchmarks.

Refining 2SVCA Method for Measuring Telehealth Accessibility of Primary Care Physicians in Baton Rouge, Louisiana.

Equity in health care delivery is a longstanding concern of public health policy. Telehealth is considered an important way to level the playing field by broadening health services access and improving quality of care and health outcomes. This study refines the recently developed "2-Step Virtual Catchment Area (2SVCA) method" to assess the telehealth accessibility of primary care in the Baton Rouge Metropolitan Statistical Area, Louisiana. The result is compared to that of spatial accessibility via physical visits to care providers based on the popular 2-Step Floating Catchment Area (2SFCA) method. The study shows that both spatial and telehealth accessibilities decline from urban to low-density and then rural areas. Moreover, disproportionally higher percentages of African Americans are in areas with higher spatial accessibility scores; but such an advantage is not realized in telehealth accessibility. In the study area, absence of broadband availability is mainly a rural problem and leads to a lower average telehealth accessibility than physical accessibility in rural areas. On the other side, lack of broadband affordability is a challenge across the rural-urban continuum and is disproportionally associated with high concentrations of disadvantaged population groups such as households under the poverty level and Blacks.

Digital Breast Tomosynthesis versus Digital Mammography Screening Performance on Successive Screening Rounds from the Breast Cancer Surveillance Consortium.

Background Prior cross-sectional studies have observed that breast cancer screening with digital breast tomosynthesis (DBT) has a lower recall rate and higher cancer detection rate compared with digital mammography (DM). Purpose To evaluate breast cancer screening outcomes with DBT versus DM on successive screening rounds. Materials and Methods In this retrospective cohort study, data from 58 breast imaging facilities in the Breast Cancer Surveillance Consortium were collected. Analysis included women aged 40-79 years undergoing DBT or DM screening from 2011 to 2020. Absolute differences in screening outcomes by modality and screening round were estimated during the study period by using generalized estimating equations with marginal standardization to adjust for differences in women's risk characteristics across modality and round. Results A total of 523 485 DBT examinations (mean age of women, 58.7 years ± 9.7 [SD]) and 1 008 123 DM examinations (mean age, 58.4 years ± 9.8) among 504 863 women were evaluated. DBT and DM recall rates decreased with successive screening round, but absolute recall rates in each round were significantly lower with DBT versus DM (round 1 difference, -3.3% [95% CI: -4.6, -2.1] [P < .001]; round 2 difference, -1.8% [95% CI: -2.9, -0.7] [P = .003]; round 3 or above difference, -1.2% [95% CI: -2.4, -0.1] [P = .03]). DBT had significantly higher cancer detection (difference, 0.6 per 1000 examinations [95% CI: 0.2, 1.1]; P = .009) compared with DM only for round 3 and above. There were no significant differences in interval cancer rate (round 1 difference, 0.00 per 1000 examinations [95% CI: -0.24, 0.30] [P = .96]; round 2 or above difference, 0.04 [95% CI: -0.19, 0.31] [P = .76]) or total advanced cancer rate (round 1 difference, 0.00 per 1000 examinations [95% CI: -0.15, 0.19] [P = .94]; round 2 or above difference, -0.06 [95% CI: -0.18, 0.11] [P = .43]). Conclusion DBT had lower recall rates and could help detect more cancers than DM across three screening rounds, with no difference in interval or advanced cancer rates. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Skaane in this issue.

Obesity-Related Discourse on Facebook and Instagram Throughout the COVID-19 Pandemic: Comparative Longitudinal Evaluation.

BACKGROUND: COVID-19 severity is amplified among individuals with obesity, which may have influenced mainstream media coverage of the disease by both improving understanding of the condition and increasing weight-related stigma. OBJECTIVE: We aimed to measure obesity-related conversations on Facebook and Instagram around key dates during the first year of the COVID-19 pandemic. METHODS: Public Facebook and Instagram posts were extracted for 29-day windows in 2020 around January 28 (the first US COVID-19 case), March 11 (when COVID-19 was declared a global pandemic), May 19 (when obesity and COVID-19 were linked in mainstream media), and October 2 (when former US president Trump contracted COVID-19 and obesity was mentioned most frequently in the mainstream media). Trends in daily posts and corresponding interactions were evaluated using interrupted time series. The 10 most frequent obesity-related topics on each platform were also examined. RESULTS: On Facebook, there was a temporary increase in 2020 in obesity-related posts and interactions on May 19 (posts +405, 95% CI 166 to 645; interactions +294,930, 95% CI 125,986 to 463,874) and October 2 (posts +639, 95% CI 359 to 883; interactions +182,814, 95% CI 160,524 to 205,105). On Instagram, there were temporary increases in 2020 only in interactions on May 19 (+226,017, 95% CI 107,323 to 344,708) and October 2 (+156,974, 95% CI 89,757 to 224,192). Similar trends were not observed in controls. Five of the most frequent topics overlapped (COVID-19, bariatric surgery, weight loss stories, pediatric obesity, and sleep); additional topics specific to each platform included diet fads, food groups, and clickbait. CONCLUSIONS: Social media conversations surged in response to obesity-related public health news. Conversations contained both clinical and commercial content of possibly dubious accuracy. Our findings support the idea that major public health announcements may coincide with the spread of health-related content (truthful or otherwise) on social media.

Disparities in spatial accessibility of primary care in Louisiana: From physical to virtual accessibility.

Telehealth has been widely employed and has transformed how healthcare is delivered in the United States as a result of COVID-19 pandemic. While telehealth is utilized and encouraged to reduce the cost and travel burden for access to healthcare, there are debates on whether telehealth can promote equity in healthcare services by narrowing the gap among diverse groups. Using the Two-Step Floating Catchment Area (2SFCA) and Two-Step Virtual Catchment Area (2SVCA) methods, this study compares the disparities of physical and virtual access to primary care physicians (PCPs) in Louisiana. Both physical and virtual access to PCPs exhibit similar spatial patterns with higher scores concentrated in urban areas, followed by low-density and rural areas. However, the two accessibility measures diverge where broadband availability and affordability come to play an important role. Residents in rural areas experience additive disadvantage of even more limited telehealth accessibility than physical accessibility due to lack of broadband service provision. Areas with greater Black population proportions tend to have better physical accessibility, but such an advantage is eradicated for telehealth accessibility because of lower broadband subscription rates in these neighborhoods. Both physical and virtual accessibility scores decline in neighborhoods with higher Area Deprivation Index (ADI) values, and the disparity is further widened for in virtual accessibility compared to than physical accessibility. The study also examines how factors such as urbanicity, Black population proportion, and ADI interact in their effects on disparities of the two accessibility measures.

National Performance Benchmarks for Screening Digital Breast Tomosynthesis: Update from the Breast Cancer Surveillance Consortium.

Background It is important to establish screening mammography performance benchmarks for quality improvement efforts. Purpose To establish performance benchmarks for digital breast tomosynthesis (DBT) screening and evaluate performance trends over time in U.S. community practice. Materials and Methods In this retrospective study, DBT screening examinations were collected from five Breast Cancer Surveillance Consortium (BCSC) registries between 2011 and 2018. Performance measures included abnormal interpretation rate (AIR), cancer detection rate (CDR), sensitivity, specificity, and false-negative rate (FNR) and were calculated based on the American College of Radiology Breast Imaging Reporting and Data System, fifth edition, and compared with concurrent BCSC DM screening examinations, previously published BCSC and National Mammography Database benchmarks, and expert opinion acceptable performance ranges. Benchmarks were derived from the distribution of performance measures across radiologists (n = 84 or n = 73 depending on metric) and were presented as percentiles. Results A total of 896 101 women undergoing 2 301 766 screening examinations (458 175 DBT examinations [median age, 58 years; age range, 18-111 years] and 1 843 591 DM examinations [median age, 58 years; age range, 18-109 years]) were included in this study. DBT screening performance measures were as follows: AIR, 8.3% (95% CI: 7.5, 9.3); CDR per 1000 screens, 5.8 (95% CI: 5.4, 6.1); sensitivity, 87.4% (95% CI: 85.2, 89.4); specificity, 92.2% (95% CI: 91.3, 93.0); and FNR per 1000 screens, 0.8 (95% CI: 0.7, 1.0). When compared with BCSC DM screening examinations from the same time period and previously published BCSC and National Mammography Database performance benchmarks, all performance measures were higher for DBT except sensitivity and FNR, which were similar to concurrent and prior DM performance measures. The following proportions of radiologists achieved acceptable performance ranges with DBT: 97.6% for CDR, 91.8% for sensitivity, 75.0% for AIR, and 74.0% for specificity. Conclusion In U.S. community practice, large proportions of radiologists met acceptable performance ranges for screening performance metrics with DBT. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Lee and Moy in this issue.