NCCN Guidelines® Insights: Breast Cancer Screening and Diagnosis, Version 1.2023.

The NCCN Guidelines for Breast Cancer Screening and Diagnosis provide health care providers with a practical, consistent framework for screening and evaluating a spectrum of clinical presentations and breast lesions. The NCCN Breast Cancer Screening and Diagnosis Panel is composed of a multidisciplinary team of experts in the field, including representation from medical oncology, gynecologic oncology, surgical oncology, internal medicine, family practice, preventive medicine, pathology, diagnostic and interventional radiology, as well as patient advocacy. The NCCN Breast Cancer Screening and Diagnosis Panel meets at least annually to review emerging data and comments from reviewers within their institutions to guide updates to existing recommendations. These NCCN Guidelines Insights summarize the panel's decision-making and discussion surrounding the most recent updates to the guideline's screening recommendations.

Implementing a Streamlined Radiology Workflow to Close the Loop on Incidental Imaging Findings in the Emergency Department.

Actionable incidental findings (AIFs) are common imaging findings unrelated to the clinical indication for the imaging test for which follow-up is recommended. Increasing utilization of imaging in the emergency department (ED) in recent years has resulted in more patients with AIFs. When these findings are not properly communicated and followed up upon, there is harm to the patient's health outcome as well as possible increased financial costs for the patient, the health system, and potential litigation. Tracking these findings can be difficult, especially so in a large health system. In this report, we detail our experience implementing a closed-loop AIF program within the ED of 11 satellite hospitals of a large academic health system. Our new workflow streamlined radiologist reporting of AIFs through system macros and by using a standardized form integrated into the dictation software. Upon completion of the form, an automatic email is sent to a dedicated nurse navigator who documented the findings and closed the loop by coordinating follow-up imaging or clinic visits with patients, primary care providers, and specialists. Through the new workflow, a total of 1207 incidental finding reports have been submitted from July 2021 to May 2022. The vast majority of AIFs were identified on CT, and the most common categories included lung nodules, pancreas lesions, liver lesions, and other potentially cancerous lesions. At least 10 new cancers have been detected. We hope this report can help guide other health systems in the design of a closed-loop incidental findings program.

Implementation of Abbreviated Breast MRI for Screening: AJR Expert Panel Narrative Review.

Abbreviated breast MRI (AB-MRI) is being rapidly adopted to harness the high sensitivity of screening MRI while addressing issues related to access, cost, and workflow. The successful implementation of an AB-MRI program requires collaboration across administrative, operational, financial, technical, and clinical providers. Institutions must be thoughtful in defining patient eligibility for AB-MRI and providing recommendations for screening intervals, as existing practices are heterogeneous. Similarly, there is no universally accepted AB-MRI protocol, though guiding principles should harmonize abbreviated and full protocols while being mindful of scan duration and amount of time patients spend on the MRI table. The interpretation of AB-MRI will be a new experience for many radiologists and may require a phased rollout and a careful audit of performance metrics over time to ensure benchmark metrics are achieved. AB-MRI finances, which are driven by patient self-payment, will require buy-in from hospital administration with the recognition that downstream revenues will be needed to support initial costs. Finally, successful startup of an AB-MRI program requires active engagement with the larger community of patients and referring providers. As AB-MRI becomes more widely accepted and available, best practices and community standards will continue to evolve to ensure high-quality patient care.

False-Negative Rates of Breast Cancer Screening with and without Digital Breast Tomosynthesis.

Background Screening with digital breast tomosynthesis (DBT) improves breast cancer detection and recall rates compared with those obtained with digital mammography (DM); however, the impact of DBT on patient survival has not been established. False-negative (FN) screening examinations can be a surrogate for long-term outcomes, such as breast cancer morbidity and mortality. Purpose To determine if screening with DBT is associated with lower FN rates, detection of cancers with more favorable prognoses, and improved performance outcomes versus DM. Materials and Methods This retrospective study involved 10 academic and community practices. DM screening examinations 1 year prior to DBT implementation and DBT screening examinations from the start date until June 30, 2013, were linked to cancers through June 30, 2014, with data collection in 2016 and analysis in 2018-2019. Cancers after FN examinations were characterized by presentation, either symptomatic or asymptomatic. FN rates, sensitivity, specificity, cancer detection and recall rates, positive predictive values, tumor size, histologic features, and receptor profile were compared. Results A total of 380 641 screening examinations were included. There were 183 989 DBT and 196 652 DM examinations. With DBT, rates trended lower for overall FN examinations (DBT, 0.6 per 1000 screens; DM, 0.7 per 1000 screens; P = .20) and symptomatic FN examinations (DBT, 0.4 per 1000 screens; DM, 0.5 per 1000 screens; P = .21). Asymptomatic FN rates trended higher in women with dense breasts (DBT, 0.14 per 1000 screens; DM: 0.07 per 1000 screens; P = .07). With DBT, improved sensitivity (DBT, 89.8% [966 of 1076 cancers]; DM, 85.6% [789 of 922 cancers]; P = .004) and specificity (DBT, 90.7% [165 830 of 182 913 examinations]; DM, 89.1% [174 480 of 195 730 examinations]; P < .001) were observed. Overall, cancers identified with DBT were more frequently invasive (P < .001), had fewer positive lymph nodes (P = .04) and distant metastases (P = .01), and had lower odds of an FN finding of advanced cancer (odds ratio, 0.9 [95% CI: 0.5, 1.5]). Conclusion Screening with digital breast tomosynthesis improves sensitivity and specificity and reveals more invasive cancers with fewer nodal or distant metastases. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Schattner in this issue.

Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium.

The COVID-19 pandemic presents clinicians a unique set of challenges in managing breast cancer (BC) patients. As hospital resources and staff become more limited during the COVID-19 pandemic, it becomes critically important to define which BC patients require more urgent care and which patients can wait for treatment until the pandemic is over. In this Special Communication, we use expert opinion of representatives from multiple cancer care organizations to categorize BC patients into priority levels (A, B, C) for urgency of care across all specialties. Additionally, we provide treatment recommendations for each of these patient scenarios. Priority A patients have conditions that are immediately life threatening or symptomatic requiring urgent treatment. Priority B patients have conditions that do not require immediate treatment but should start treatment before the pandemic is over. Priority C patients have conditions that can be safely deferred until the pandemic is over. The implementation of these recommendations for patient triage, which are based on the highest level available evidence, must be adapted to current availability of hospital resources and severity of the COVID-19 pandemic in each region of the country. Additionally, the risk of disease progression and worse outcomes for patients need to be weighed against the risk of patient and staff exposure to SARS CoV-2 (virus associated with the COVID-19 pandemic). Physicians should use these recommendations to prioritize care for their BC patients and adapt treatment recommendations to the local context at their hospital.

Abbreviated Protocol Breast MRI.

OBJECTIVE. Patients with dense breast tissue are seeking supplemental screening because of the limited sensitivity of mammography. Abbreviated protocol (AP) breast MRI is attractive because it offers a higher cancer detection rate, shorter scan time, and lower cost than full MRI. This article explores the issues of balancing the benefits of AP MRI with safety concerns about gadolinium-based contrast agents, lack of standardization of protocols and field strengths, potential decrease in performance metrics, and potential for overdiagnosis. CONCLUSION. Important questions need to be addressed before AP MRI can be used routinely for breast cancer screening. Evidence is lacking from well-designed prospective trials that can confirm the accuracy and efficacy of AP MRI are comparable with those of other breast imaging modalities. Determining which patients benefit most from AP MRI will help shape future screening guidelines.

Quantifying the decrease in emergency department imaging utilization during the COVID-19 pandemic at a multicenter healthcare system in Ohio.

PURPOSE: To illustrate the change in emergency department (ED) imaging utilization at a multicenter health system in the state of Ohio during the COVID-19 pandemic. METHODS: A retrospective observational study was conducted assessing ED imaging volumes between March 1, 2020, and May 11, 2020, during the COVID-19 crisis. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization in the ED was compared with new COVID-19 cases in our region. Utilization was first categorized by modality and then by plain films and computed tomography (CT) scans grouped by body part. CT imaging of the chest was specifically investigated by assessing both CT chest only exams and CT chest, abdomen, and pelvis (C/A/P) exams. Ultimately, matching pair-wise statistical analysis of exam volumes was performed to assess significance of volume change. RESULTS: Our multicenter health system experienced a 46% drop in imaging utilization (p < 0.0001) during the pandemic. Matching pair-wise analysis showed a statistically significant volume decrease by each modality and body part. The exceptions were non-contrast chest CT, which increased (p = 0.0053), and non-trauma C/A/P CT, which did not show a statistically significant volume change (p = 0.0633). CONCLUSION: ED imaging utilization trends revealed through actual health system data will help inform evidence-based decisions for more accurate volume predictions and therefore institutional preparedness for current and future pandemics.

Three-dimensional MR Fingerprinting for Quantitative Breast Imaging.

Purpose To develop a fast three-dimensional method for simultaneous T1 and T2 quantification for breast imaging by using MR fingerprinting. Materials and Methods In this prospective study, variable flip angles and magnetization preparation modules were applied to acquire MR fingerprinting data for each partition of a three-dimensional data set. A fast postprocessing method was implemented by using singular value decomposition. The proposed technique was first validated in phantoms and then applied to 15 healthy female participants (mean age, 24.2 years ± 5.1 [standard deviation]; range, 18-35 years) and 14 female participants with breast cancer (mean age, 55.4 years ± 8.8; range, 39-66 years) between March 2016 and April 2018. The sensitivity of the method to B1 field inhomogeneity was also evaluated by using the Bloch-Siegert method. Results Phantom results showed that accurate and volumetric T1 and T2 quantification was achieved by using the proposed technique. The acquisition time for three-dimensional quantitative maps with a spatial resolution of 1.6 × 1.6 × 3 mm3 was approximately 6 minutes. For healthy participants, averaged T1 and T2 relaxation times for fibroglandular tissues at 3.0 T were 1256 msec ± 171 and 46 msec ± 7, respectively. Compared with normal breast tissues, higher T2 relaxation time (68 msec ± 13) was observed in invasive ductal carcinoma (P < .001), whereas no statistical difference was found in T1 relaxation time (1183 msec ± 256; P = .37). Conclusion A method was developed for breast imaging by using the MR fingerprinting technique, which allows simultaneous and volumetric quantification of T1 and T2 relaxation times for breast tissues. © RSNA, 2018 Online supplemental material is available for this article.

Implementing Abbreviated MRI Screening Into a Breast Imaging Practice.

OBJECTIVE. The purpose of this article is to describe steps for implementing abbreviated breast MRI into a breast imaging practice. CONCLUSION. Mammographic screening for breast cancer has been the standard of care. However, breast cancer remains a leading cause of death of women. Studies have shown that MRI performed with an abbreviated protocol for women at average and slightly increased risk depicts mammographically occult biologically significant cancers at early stages.

Intratumoral and peritumoral radiomics for the pretreatment prediction of pathological complete response to neoadjuvant chemotherapy based on breast DCE-MRI.

BACKGROUND: In this study, we evaluated the ability of radiomic textural analysis of intratumoral and peritumoral regions on pretreatment breast cancer dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to predict pathological complete response (pCR) to neoadjuvant chemotherapy (NAC). METHODS: A total of 117 patients who had received NAC were retrospectively analyzed. Within the intratumoral and peritumoral regions of T1-weighted contrast-enhanced MRI scans, a total of 99 radiomic textural features were computed at multiple phases. Feature selection was used to identify a set of top pCR-associated features from within a training set (n = 78), which were then used to train multiple machine learning classifiers to predict the likelihood of pCR for a given patient. Classifiers were then independently tested on 39 patients. Experiments were repeated separately among hormone receptor-positive and human epidermal growth factor receptor 2-negative (HR+, HER2-) and triple-negative or HER2+ (TN/HER2+) tumors via threefold cross-validation to determine whether receptor status-specific analysis could improve classification performance. RESULTS: Among all patients, a combined intratumoral and peritumoral radiomic feature set yielded a maximum AUC of 0.78 ± 0.030 within the training set and 0.74 within the independent testing set using a diagonal linear discriminant analysis (DLDA) classifier. Receptor status-specific feature discovery and classification enabled improved prediction of pCR, yielding maximum AUCs of 0.83 ± 0.025 within the HR+, HER2- group using DLDA and 0.93 ± 0.018 within the TN/HER2+ group using a naive Bayes classifier. In HR+, HER2- breast cancers, non-pCR was characterized by elevated peritumoral heterogeneity during initial contrast enhancement. However, TN/HER2+ tumors were best characterized by a speckled enhancement pattern within the peritumoral region of nonresponders. Radiomic features were found to strongly predict pCR independent of choice of classifier, suggesting their robustness as response predictors. CONCLUSIONS: Through a combined intratumoral and peritumoral radiomics approach, we could successfully predict pCR to NAC from pretreatment breast DCE-MRI, both with and without a priori knowledge of receptor status. Further, our findings suggest that the radiomic features most predictive of response vary across different receptor subtypes.

Effect of age on breast cancer screening using tomosynthesis in combination with digital mammography.

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.

Improved Screening Mammogram Workflow by Maximizing PACS Streamlining Capabilities in an Academic Breast Center.

The aim of this study was to perform an operational improvement project targeted at the breast imaging reading workflow of mammography examinations at an academic medical center with its associated breast centers and satellite sites. Through careful analysis of the current workflow, two major issues were identified: stockpiling of paperwork and multiple worklists. Both issues were considered to cause significant delays to the start of interpreting screening mammograms. Four workflow changes were suggested (scanning of paperwork, worklist consolidation, use of chat functionality, and tracking of case distribution among trainees) and implemented in July 2015. Timestamp data was collected 2 months before (May-Jun) and after (Aug-Sep) the implemented changes. Generalized linear models were used to analyze the data. The results showed significant improvements for the interpretation of screening mammograms. The average time elapsed for time to open a case reduced from 70 to 28 min (60 % decrease, p < 0.001), report turn-around time with preliminary signature decreased from 151 to 107 min (29 % decrease, p < 0.001), and report turn-around time final signature from 153 to 139 min (9 % decrease, p = 0.002). These improvements were achieved while keeping the efficiency of the workflow for diagnostic mammograms at large unaltered even with increased volume of mammography examinations (31 % increase of 4344 examinations for May-Jun to 5678 examinations for Aug-Sep). In conclusion, targeted efforts to improve the breast imaging reading workflow for screening mammograms in a teaching environment provided significant performance improvements without affecting the workflow of diagnostic mammograms.

Diagnostic power of diffuse reflectance spectroscopy for targeted detection of breast lesions with microcalcifications.

Microcalcifications geographically target the location of abnormalities within the breast and are of critical importance in breast cancer diagnosis. However, despite stereotactic guidance, core needle biopsy fails to retrieve microcalcifications in up to 15% of patients. Here, we introduce an approach based on diffuse reflectance spectroscopy for detection of microcalcifications that focuses on variations in optical absorption stemming from the calcified clusters and the associated cross-linking molecules. In this study, diffuse reflectance spectra are acquired ex vivo from 203 sites in fresh biopsy tissue cores from 23 patients undergoing stereotactic breast needle biopsies. By correlating the spectra with the corresponding radiographic and histologic assessment, we have developed a support vector machine-derived decision algorithm, which shows high diagnostic power (positive predictive value and negative predictive value of 97% and 88%, respectively) for diagnosis of lesions with microcalcifications. We further show that these results are robust and not due to any spurious correlations. We attribute our findings to the presence of proteins (such as elastin), and desmosine and isodesmosine cross-linkers in the microcalcifications. It is important to note that the performance of the diffuse reflectance decision algorithm is comparable to one derived from the corresponding Raman spectra, and the considerably higher intensity of the reflectance signal enables the detection of the targeted lesions in a fraction of the spectral acquisition time. Our findings create a unique landscape for spectroscopic validation of breast core needle biopsy for detection of microcalcifications that can substantially improve the likelihood of an adequate, diagnostic biopsy in the first attempt.

Improving the Accuracy of Axillary Lymph Node Surgery in Breast Cancer with Ultrasound-Guided Wire Localization of Biopsy Proven Metastatic Lymph Nodes.

BACKGROUND: This study aimed to evaluate whether the use of preoperative ultrasound (US)-guided wire localization of metastatic axillary lymph nodes (LN) assessed previously by core needle biopsy (CNB) and clip placement in breast cancer patients improves successful surgical removal. METHODS: A retrospective review examined breast cancer patients who underwent US-guided CNB of an axillary LN and biopsy clip placement as well as axillary lymph node dissection (ALND) or sentinel node lymph node biopsy (SLNB) from 1 January 2010 to 30 September 2013. Preoperative needle localization status, neoadjuvant chemotherapy, and type of axillary LN surgery were reviewed. Confirmation that the metastatic LN had been surgically removed was determined on the specimen image, by pathologic report confirmation, or by pre-radiation therapy computed tomography (CT) scan. RESULTS: Preoperative US-guided needle localization was performed for 68.2 % (73/107) of the patients, with 97.3 % (n = 71) demonstrating confirmation of biopsy clip and LN removal versus 79.4 % (n = 27) of the 34 patients showing no performance of needle localization (p = 0.0043). Subgroup analysis showed a significant difference in removal of metastatic LN between the patients who received neoadjuvant chemotherapy [97 % of LNs removed with wire localization (n = 65/67) vs. 83.3 % of LNs removed without wire localization (n = 20/24; p = 0.04)] and the patients who had ALND, [96.3 % of LNs removed with wire localization (n = 52/54) vs. 77.8 % of LNs removed without wire localization (n = 21/27; p = 0.015)]. CONCLUSION: US-guided wire localization of metastatic axillary LNs that have had biopsy with clip placement significantly improves the success rate of surgical removal, allowing more accurate staging and decreasing the false-negative rates of SLNB after neoadjuvant therapy.

Addition of shear-wave elastography during second-look MR imaging-directed breast US: effect on lesion detection and biopsy targeting.

PURPOSE: To determine if adding shear-wave elastography (SWE) to second-look ultrasonography (US) after breast dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging helps find or target lesions seen on DCE MR images for US-guided biopsy. MATERIALS AND METHODS: This HIPAA-compliant prospective study was approved by the institutional review board, and written informed consent was obtained from patients. From May 2011 to July 2012, 73 women with 96 Breast Imaging Reporting and Data System (BI-RADS) category 4 or 5 lesions after DCE MR imaging prospectively consented to undergo SWE during second-look US. If a lesion was not confidently seen with B-mode US, SWE during real-time scanning was performed to determine if SWE helped find or target lesions for US biopsy. A qualitative SWE six-point color scale was used to record the maximum elasticity in and around lesions. All lesions underwent US or DCE MR imaging-guided core biopsy. RESULTS: Median participant age was 52 years (range, 21-81 years). In 72 patients who underwent DCE MR imaging, 96 BI-RADS category 4 or 5 lesions were detected in 81 breasts. There were 29 (30%) malignancies (one malignancy was of nonbreast origin), 14 (15%) high-risk lesions, and 53 (55%) benign lesions. US revealed 22 cancers, and seven cancers were detected only with MR imaging. Real-time SWE helped find one lesion and target four lesions that were incompletely assessed with gray-scale US. These five lesions that were localized or targeted for biopsy were invasive cancers, representing 23% of the 22 malignancies detected with US. CONCLUSION: Real-time SWE added to second-look US after DCE MR imaging increased the detection rate of cancers and helped target cancers for US-guided biopsy.

Neglecting to screen women between 40 and 49 years old with mammography: what is the impact on treatment morbidity and potential risk reduction?

OBJECTIVE: The purpose of this study is to determine whether there were significant differences with respect to treatment recommendations, stage at diagnosis, and identification of high-risk lesions for women 40-49 years old undergoing screening mammography (screened) compared to women with a symptom needing a diagnostic evaluation (nonscreened). MATERIALS AND METHODS: We reviewed the pathology results of all imaging-guided biopsies performed at the three breast center locations of University Hospitals Case Medical Center from January 1, 2008, to December 31, 2011. In patients diagnosed with a high-risk lesion or breast cancer, the reason for presentation, pathology, tumor size, stage, receptor characteristics, and treatment were recorded. The chi-square test was used for statistical analysis. RESULTS: Of 230 primary breast cancers, 149 were in the screened group and 81 were considered nonscreened. Nonscreened patients were more likely to undergo chemotherapy (p = 0.042). Eighty-one percent of the high-risk lesions were diagnosed in the screened patients. Screened patients with cancer were significantly more likely to receive a diagnosis at earlier stages (p = 0.001), to have negative axillary lymph nodes (p = 0.005), and to have smaller tumors (p < 0.001). CONCLUSION: In addition to the benefits of receiving a diagnosis at earlier stages, with smaller tumors and node negativity, patients with breast cancer undergoing screening mammography aged 40-49 years are less likely to require chemotherapy and its associated morbidities. The majority of high-risk lesions were diagnosed in the screened group, which may lead to the benefit of chemoprevention, lowering their risk of subsequent breast cancer, or screening with MRI, which may diagnose future mammographically occult malignancies.

Breast cancer screening using tomosynthesis in combination with digital mammography.

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 mammography was 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.

System-driven longitudinal follow-up of incidental imaging findings.

Increasing utilization of cross-sectional imaging has resulted in more clinically significant incidental findings being discovered. However, the current approach for handling these findings is commonly inconsistent and relies greatly on the efforts of individual clinicians. Making sure every actionable incidental finding is handled in a consistent and reliable manner can be difficult, especially for a large health system. We propose an approach to handling incidental findings aimed at improving patient follow-up rates, which involves implementing system-level processes that standardize the reporting of incidental findings, notification of clinicians and the patient, and centralized monitoring of longitudinal patient follow-up. We will lay out a general framework for standardized reporting of incidental findings by the radiologist using software integrated into the daily workflow. This should enable simultaneous notification of the ordering clinician, the patient's primary-care provider, and an incidental findings navigator. The navigator will "close the loop" by working with clinicians to notify the patient of the finding, coordinate patient follow-up, and document the finding and long-term follow-up. We hope this can serve as a basic framework to help large health systems design an incidental findings workflow to improve follow-up rates and reduce patient harm.

Abbreviated Breast MRI: Our Two-Year Initial Experience.

OBJECTIVE: The aim of this study was to retrospectively evaluate and present our two-year experience with abbreviated breast MRI at our academic institution as a screening tool to identify primary breast cancers. METHODS: Employing eight specialty trained breast radiologists, studies were interpreted using the BI-RADS MRI lexicon in this IRB-approved retrospective study. The protocol utilized T1-weighted, fat-saturated, pre- and post-contrast, short T1 inversion recovery images, and was completed within 10 minutes. Abbreviated breast MRI was offered to asymptomatic women of all breast densities, whose ages ranged from 24 to 90 years. Statistical analysis was performed for comparative data utilizing estimated odds ratios. RESULTS: Of 1338 patients that met inclusion criteria, 83% (1111/1338) were BI-RADS 1 or 2, 9.0% (121/1338) were BI-RADS 3, and 8% (106/1338) were categorized as either BI-RADS 4 or 5 with recommended biopsy. Biopsy of BI-RADS 4 and 5 categorized patients yielded 15 cancers for a positive predictive value (PPV) 2 of 14.2% and a PPV3 of 18.5%, with 76% (81/106) of patients undergoing the recommended biopsy. An additional cancer was detected in a BI-RADS 3 finding. All cancers detected were in women with heterogeneously dense or extremely dense breasts. Therefore, 16 cancers were detected, yielding a cancer detection rate of 12.0 per 1000. Over the next 12 to 24 months, no interval cancers were detected. CONCLUSION: Abbreviated breast MRI demonstrates a higher cancer detection rate compared with mammography only and may provide a supplemental screening method to detect breast cancers in patients with varying risk factors.