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.

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.

Novel Radiomic Measurements of Tumor-Associated Vasculature Morphology on Clinical Imaging as a Biomarker of Treatment Response in Multiple Cancers.

PURPOSE: The tumor-associated vasculature (TAV) differs from healthy blood vessels by its convolutedness, leakiness, and chaotic architecture, and these attributes facilitate the creation of a treatment-resistant tumor microenvironment. Measurable differences in these attributes might also help stratify patients by likely benefit of systemic therapy (e.g., chemotherapy). In this work, we present a new category of computational image-based biomarkers called quantitative tumor-associated vasculature (QuanTAV) features, and demonstrate their ability to predict response and survival across multiple cancer types, imaging modalities, and treatment regimens involving chemotherapy. EXPERIMENTAL DESIGN: We isolated tumor vasculature and extracted mathematical measurements of twistedness and organization from routine pretreatment radiology (CT or contrast-enhanced MRI) of a total of 558 patients, who received one of four first-line chemotherapy-based therapeutic intervention strategies for breast (n = 371) or non-small cell lung cancer (NSCLC, n = 187). RESULTS: Across four chemotherapy-based treatment strategies, classifiers of QuanTAV measurements significantly (P < 0.05) predicted response in held out testing cohorts alone (AUC = 0.63-0.71) and increased AUC by 0.06-0.12 when added to models of significant clinical variables alone. Similarly, we derived QuanTAV risk scores that were prognostic of recurrence-free survival in treatment cohorts who received surgery following chemotherapy for breast cancer [P = 0.0022; HR = 1.25; 95% confidence interval (CI), 1.08-1.44; concordance index (C-index) = 0.66] and chemoradiation for NSCLC (P = 0.039; HR = 1.28; 95% CI, 1.01-1.62; C-index = 0.66). From vessel-based risk scores, we further derived categorical QuanTAV high/low risk groups that were independently prognostic among all treatment groups, including patients with NSCLC who received chemotherapy only (P = 0.034; HR = 2.29; 95% CI, 1.07-4.94; C-index = 0.62). QuanTAV response and risk scores were independent of clinicopathologic risk factors and matched or exceeded models of clinical variables including posttreatment response. CONCLUSIONS: Across these domains, we observed an association of vascular morphology on CT and MRI-as captured by metrics of vessel curvature, torsion, and organizational heterogeneity-and treatment outcome. Our findings suggest the potential of shape and structure of the TAV in developing prognostic and predictive biomarkers for multiple cancers and different treatment strategies.

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.

Relationship Building as a Strategy for Managing Referring Clinicians.

The strength of a radiology practice depends on the strong relationships radiologists develop with referring clinicians. Solid relationships with referring clinicians can contribute to a satisfying work environment, and ultimately excellent patient care. There are several different ways that a radiologist can help improve relationships with clinicians. As a start, this includes a radiologist strengthening one's emotional intelligence. Also, identifying the personality traits of others is key to successful interactions. Conflicts in the workplace are inevitable, and effective negotiation is helpful in building relationships with clinicians. Interacting with the referring clinicians is also key to a successful relationship. This includes all in-person communication, participating in tumor boards, community outreach events, and social functions outside of work. This article presents several tips to improve and manage relationships with referring clinicians.

Abbreviated Breast MRI Utilization: A Survey of the Society of Breast Imaging.

OBJECTIVE: To survey Society of Breast Imaging (SBI) membership on their use of abbreviated breast MRI to understand variability in practice patterns. METHODS: A survey was developed by the SBI Patient Care and Delivery committee for distribution to SBI membership in July and August 2021. Eighteen questions queried practice demographics and then abbreviated breast MRI practices regarding initial adoption, scheduling and finances, MRI protocols, and interpretations. Comparisons between responses were made by practice demographics. RESULTS: There were 321 respondents (response rate: 15.3%), of whom 25% (81/321) currently offer and 26% (84/321) plan to offer abbreviated breast MRI. Practices in the South (37/107, 35%) and Midwest (22/70, 31%) were more likely to offer abbreviated MRI (P = 0.005). Practices adopted many strategies to raise awareness, most directed at referring providers. The mean charge to patients was $414, and only 6% of practices offer financial support. The median time slot for studies is 20 minutes, with only 15% of practices using block scheduling of consecutive breast MRIs. Regarding MRI protocols, 64% (37/58) of respondents included only a single first-pass post-contrast sequence, and 90% (52/58) included T2-weighted sequences. Patient eligibility was highly varied, and a majority of respondents (37/58, 64%) do not provide any recommendations for screening intervals in non-high-risk women. CONCLUSION: Abbreviated breast MRI utilization is growing rapidly, and practices are applying a variety of strategies to facilitate adoption. Although there is notable variability in patient eligibility, follow-up intervals, and costs, there is some agreement regarding abbreviated breast MRI protocols.

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.

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.

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.

COVID-19 Pandemic Impact on Decreased Imaging Utilization: A Single Institutional Experience.

RATIONALE AND OBJECTIVES: Predictive models and anecdotal articles suggest radiology practices were losing 50%-70% of their normal imaging volume during the COVID-19 pandemic. Using actual institutional data, we investigated the change in imaging utilization and revenue during this public health crisis. MATERIALS AND METHODS: Imaging performed within the 8-week span between March 8 and April 30, 2020 was categorized into the COVID-19 healthcare crisis timeframe. The first week of this date range and the 10 weeks prior were used to derive the normal practice expected volume. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization was derived and organized by patient setting (outpatient, inpatient, emergency) and imaging modality (X-ray, CT, Mammography, MRI, Nuclear Medicine/PET, US). The three highest volume hospitals were analyzed. Revenue information was collected from the hospital billing system. RESULTS: System-wide imaging volume decreased by 55% between April 7 and 13, 2020. Outpatient exams decreased by 68% relative to normal practice. Emergency exams decreased by 48% and inpatient exams declined by 31%. Mammograms and nuclear medicine scans were the most affected modalities, decreasing by 93% and 61%, respectively. The main campus hospital experienced less relative imaging volume loss compared to the other smaller and outpatient-driven hospitals. At its lowest point, the technical component revenue from main campus imaging services demonstrated a 49% negative variance from normal practice. CONCLUSION: The trends and magnitude of the actual imaging utilization data presented will help inform evidence-based decisions for more accurate volume predictions, policy changes, and institutional preparedness for current and future pandemics.

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.

Fast MRI breast cancer screening - Ready for prime time.

OBJECTIVE: The manuscript discusses landmark studies using abbreviated MRI for breast cancer screening. This includes abbreviated dynamic contrast enhanced MRI and diffusion weighted imaging. Our institutional experience with abbreviated MR protocol for breast cancer screening is also described. CONCLUSION: Abbreviated MRI protocols were found to demonstrate value for screening of breast cancer. It has been shown that abbreviated protocol MRI provides similar diagnostic sensitivities to full protocol MRI for breast cancer in women with increased lifetime risk. Our institutional abbreviated MRI protocol for breast cancer offers improved time and workflow efficiencies and has the potential to increase the number of breast cancers detected and the detection of pathologically relevant invasive breast cancer at earlier stages.

Setting Up an Abbreviated Breast MRI Program: Our Two-year Implementation Experience.

Mammography is the long-standing screening tool for detecting breast cancer. Breast MRI is the most sensitive screening modality; however, it has been reserved for patients who are at an increased risk of developing breast cancer. Abbreviated breast MRI (AB-MRI) overcomes the limitations of cost and scanner time when considering screening patients at average or slightly elevated risk. This paper discusses the practical considerations for implementing an AB-MRI program on many levels, after our two-year experience. One of the first steps in introducing an AB-MRI program, since there is no standardized protocol, is determining and implementing a protocol. Since there is no Current Procedural Terminology code for an AB-MRI, a self-pay charge should be established. Adjusting MRI scheduling templates to accommodate the 10-minute AB-MRI exam is helpful. Communication with the breast team and the education of referring physicians is a key step to ensure awareness of a new screening option. As the AB-MRI program is incorporated into a practice, auditing of routine screening outcomes several months after commencement is invaluable to the continued success of the program.

Utilization of Patient Navigators in Breast Imaging Facilities Across the United States: A Survey of Breast Imaging Radiologists.

OBJECTIVE: To assess the utilization of patient navigators at breast imaging facilities across the United States. METHODS: An online survey was distributed to physician members of the Society of Breast Imaging. Questions encompassed use of patient navigators in breast imaging including: presence and qualifications, roles in patient care, perceived benefits, and barriers. Data were analyzed to identify the overall prevalence of patient navigators, their responsibilities and qualifications, and the impact on breast imaging centers. RESULTS: Three-hundred and eighty-five board-certified radiologists practicing in the United States completed the survey. The most common practice types were private practice (52%; 201/385) and academic (29%; 110/385). The majority (67%; 256/385) employed navigators, and the most common qualification was a registered nurse (78%; 200/256). Navigators were used for a variety of patient communication and care coordination roles, most commonly to provide educational resources (86%; 219/256), assist patients with scheduling appointments (80%; 205/256), explain the biopsy process (76%;195/256), and communicate biopsy results (64%). Nearly all (99%; 254/256) respondents ranked patient navigators as valuable to extremely valuable in improving patient care and indicated they would recommend implementation of a patient navigation program to other breast imaging practices. The most common barrier to employing a navigator was the financial cost. CONCLUSION: Patient navigators have been widely adopted in breast imaging practices across the United States, with two-thirds of respondents reporting use of a navigator. Although navigator roles varied by practice, nearly all radiologists utilizing patient navigators found that they positively impact patient care and would recommend them to other breast imaging practices.

Association of Peritumoral Radiomics With Tumor Biology and Pathologic Response to Preoperative Targeted Therapy for HER2 (ERBB2)-Positive Breast Cancer.

Importance: There has been significant recent interest in understanding the utility of quantitative imaging to delineate breast cancer intrinsic biological factors and therapeutic response. No clinically accepted biomarkers are as yet available for estimation of response to human epidermal growth factor receptor 2 (currently known as ERBB2, but referred to as HER2 in this study)-targeted therapy in breast cancer. Objective: To determine whether imaging signatures on clinical breast magnetic resonance imaging (MRI) could noninvasively characterize HER2-positive tumor biological factors and estimate response to HER2-targeted neoadjuvant therapy. Design, Setting, and Participants: In a retrospective diagnostic study encompassing 209 patients with breast cancer, textural imaging features extracted within the tumor and annular peritumoral tissue regions on MRI were examined as a means to identify increasingly granular breast cancer subgroups relevant to therapeutic approach and response. First, among a cohort of 117 patients who received an MRI prior to neoadjuvant chemotherapy (NAC) at a single institution from April 27, 2012, through September 4, 2015, imaging features that distinguished HER2+ tumors from other receptor subtypes were identified. Next, among a cohort of 42 patients with HER2+ breast cancers with available MRI and RNaseq data accumulated from a multicenter, preoperative clinical trial (BrUOG 211B), a signature of the response-associated HER2-enriched (HER2-E) molecular subtype within HER2+ tumors (n = 42) was identified. The association of this signature with pathologic complete response was explored in 2 patient cohorts from different institutions, where all patients received HER2-targeted NAC (n = 28, n = 50). Finally, the association between significant peritumoral features and lymphocyte distribution was explored in patients within the BrUOG 211B trial who had corresponding biopsy hematoxylin-eosin-stained slide images. Data analysis was conducted from January 15, 2017, to February 14, 2019. Main Outcomes and Measures: Evaluation of imaging signatures by the area under the receiver operating characteristic curve (AUC) in identifying HER2+ molecular subtypes and distinguishing pathologic complete response (ypT0/is) to NAC with HER2-targeting. Results: In the 209 patients included (mean [SD] age, 51.1 [11.7] years), features from the peritumoral regions better discriminated HER2-E tumors (maximum AUC, 0.85; 95% CI, 0.79-0.90; 9-12 mm from the tumor) compared with intratumoral features (AUC, 0.76; 95% CI, 0.69-0.84). A classifier combining peritumoral and intratumoral features identified the HER2-E subtype (AUC, 0.89; 95% CI, 0.84-0.93) and was significantly associated with response to HER2-targeted therapy in both validation cohorts (AUC, 0.80; 95% CI, 0.61-0.98 and AUC, 0.69; 95% CI, 0.53-0.84). Features from the 0- to 3-mm peritumoral region were significantly associated with the density of tumor-infiltrating lymphocytes (R2 = 0.57; 95% CI, 0.39-0.75; P = .002). Conclusions and Relevance: A combination of peritumoral and intratumoral characteristics appears to identify intrinsic molecular subtypes of HER2+ breast cancers from imaging, offering insights into immune response within the peritumoral environment and suggesting potential benefit for treatment guidance.

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.

Changes in the Utilization of the BI-RADS Category 3 Assessment in Recalled Patients Before and After the Implementation of Screening Digital Breast Tomosynthesis.

RATIONALE AND OBJECTIVES: The purpose of this study was to compare the utilization of the Breast Imaging Reporting and Data System (BI-RADS) category 3 assessment in patients recalled from screening before and after the implementation of digital breast tomosynthesis (DBT). MATERIALS AND METHODS: This was a retrospective review of 11,478 digital mammography (DM) screening exams and 9350 DM+DBT screening exams. Lesions assigned a BI-RADS category 3 at diagnostic exam were classified as architectural distortions, asymmetries, calcifications, masses, and "other" and followed for a minimum of 2 years. RESULTS: The addition of DBT to screening DM resulted in a 30.4% relative reduction (10.3 women per 1000) in the utilization of BI-RADS category 3 compared to screening DM alone (3.4% for DM versus 2.4% for DM+DBT; p < 0.0001). There was a statistically significant change in the distribution of category 3 findings with DM+DBT characterized by an increase in calcifications and architectural distortions and a decrease in asymmetries. There was no change in category 3 assessment for masses. Although both cohorts had delayed cancer detection rates that exceeded the recommended 2% benchmark (2.3% for DM and 3.6% for DM+DBT), when limited to invasive malignancies, the delayed cancer detection rates were below the 2% benchmark (1.5% for DM and 0.9% for DM+DBT). Screening DM+DBT resulted in a 9.2% relative reduction in recall rate compared to DM (13.0% for DM versus 11.8% for DM+ DBT, p = 0.012). CONCLUSION: Implementation of DBT in the screening population decreased the overall number of patients assigned to short-term follow-up by 10.3 per 1000 women while maintaining comparable rates of delayed cancer detection.