Impact of Breast Density Legislation on Breast Cancer Risk Assessment and Supplemental Screening: A Survey of 110 Radiology Facilities.

Breast density notification laws, passed in 19 states as of October 2014, mandate that patients be informed of their breast density. The purpose of this study is to assess the impact of this legislation on radiology practices, including performance of breast cancer risk assessment and supplemental screening studies. A 20-question anonymous web-based survey was emailed to radiologists in the Society of Breast Imaging between August 2013 and March 2014. Statistical analysis was performed using Fisher's exact test. Around 121 radiologists from 110 facilities in 34 USA states and 1 Canadian site responded. About 50% (55/110) of facilities had breast density legislation, 36% of facilities (39/109) performed breast cancer risk assessment (one facility did not respond). Risk assessment was performed as a new task in response to density legislation in 40% (6/15) of facilities in states with notification laws. However, there was no significant difference in performing risk assessment between facilities in states with a law and those without (p < 0.831). In anticipation of breast density legislation, 33% (16/48), 6% (3/48), and 6% (3/48) of facilities in states with laws implemented handheld whole breast ultrasound (WBUS), automated WBUS, and tomosynthesis, respectively. The ratio of facilities offering handheld WBUS was significantly higher in states with a law than in states without (p < 0.001). In response to breast density legislation, more than 33% of facilities are offering supplemental screening with WBUS and tomosynthesis, and many are performing formal risk assessment for determining patient management.

Risk assessment, screening and prevention of breast cancer: A look at cost-effectiveness.

Recent suggestions by the United States Preventive Task Force to change the longstanding guidelines for screening mammography have raised the issue of cost-effectiveness in regards to breast cancer detection. Given the enormous number of women who have had, or who will be diagnosed with breast cancer, it is essential to maintain the quality of care that has been achieved here in the United States while utilizing a cost-effective approach. The following review attempts a close examination of current methods available for risk assessment, screening and prevention programs. These programs must be carefully considered and analyzed prior to implementing cost-saving changes to current clinical standards that have proven successful in decreasing the mortality from breast cancer throughout the world.

Proceedings of the international consensus conference on breast cancer risk, genetics, & risk management, April, 2007.

A consensus conference including thirty experts was held in April, 2007, to discuss risk factors for breast cancer and their management. Four categories of risk were outlined, from breast cancer "average" through "very high" risk, the latter including individuals with high penetrance BRCA1/2 gene mutations. Guidelines for management of patients in each of these categories were discussed, with the major portion of the conference being devoted to individuals with BRCA1/2 mutations. Prevalence of these mutations in the general populations was estimated to be 1 in 250-500 individuals, with an increased prevalence in Ashkenazic Jews and other founder groups. Risk reduction strategies for these individuals include surveillance, with or without chemoprevention drugs, or surgical procedures to remove the organs at risk, i.e., bilateral mastectomy and/or bilateral salpingo-oophorectomy. These risk reduction strategies were evaluated fully, and recommendations were made for the care of patients in each of the risk categories. These guidelines for patient care were approved by the entire group of experts.

Professional and economic factors affecting access to mammography: a crisis today, or tomorrow? Results from a national survey.

BACKGROUND: Objective data and anecdotal reports have suggested that access to mammography may be declining because of facility closures and difficulty in recruiting and retaining radiologists and radiologic technologists. To gain insight into the practice patterns, use of emerging technologies, and concerns of breast imagers in current practice, the Society of Breast Imaging (SBI) conducted a national survey of breast imaging practices in the U.S. METHODS: Between October 2003 and April 2004, the SBI conducted a survey of the SBI membership database, and received completed surveys from 575 breast imaging practices in the U.S. Responses to the survey regarding practice characteristics, the utilization of standard and emerging technologies, staffing, malpractice, finance, and morale were analyzed. RESULTS: Job vacancies for radiologists who read mammograms were reported in 163 practices (29%), 59 of which (10%) had 2 or more openings. A higher proportion of practices with job openings had long appointment waiting times for asymptomatic women when compared with fully staffed practices. Unfilled fellowship positions also were common, with 41 of 65 practices that offer fellowships reporting 47 openings. Among 554 responding practices, 55% reported that someone in their practice was sued because of a mammography related case within the past 5 years, and 50% of practices reported that the threat of lawsuits made radiologist staffing "moderately" or "a lot" more difficult. Of 521 responding practices, 35% reported financial losses in 2002. One in 5 respondents reported that they would prefer to spend less time in mammography, and fewer than 1 in 3 would recommend a breast imaging fellowship to a relative or friend. Emerging technologies, such as breast magnetic resonance imaging and screening ultrasound, currently are being performed in many practices. CONCLUSIONS: The survey results provide support for anecdotal reports that breast imaging practices face significant challenges and stresses, including shortages of key personnel, a lack of trainees, malpractice concerns, financial constraints, increased workload due to emerging technologies, low appeal of breast imaging as a career specialty, and the steady rise in the population of women of screening age.

Screening mammography controversies: resolved, partly resolved, and unresolved.

Since the 1960s, multiple randomized clinical trials have measured differences in breast cancer mortality between women 40 and 70 years of age who were offered screening mammography and control group women. This article describes briefly these trials, which nearly universally documented statistically significant reductions in breast cancer deaths. These trials also underestimated the benefit, regardless of age, due to screening parameters that were not optimized. In recent years, published articles analyzing studies of Swedish women have claimed that there is no reduction in overall mortality from breast cancer and other causes among women offered screening. Critical assessment of these articles noted that breast cancer deaths were less than 5% of all deaths and that no statistically significant reduction in overall mortality rates should be expected within the population that had been analyzed. The latest screening mammography controversies involve potential adverse consequences and risks, such as X-ray exposure, detection of ductal carcinoma in situ (DCIS), and "excessive" callback rates for additional imaging studies. Despite these controversies, the preponderance of scientific evidence continues to strongly support annual screening mammography for women 40 years of age and older.

Survey of radiology residents: breast imaging training and attitudes.

PURPOSE: To investigate the training and attitudes of residents regarding breast imaging. MATERIALS AND METHODS: A telephone survey was conducted with 201 4th-year residents (postgraduate medical school year 5) and 10 3rd-year residents (postgraduate medical school year 4) at 211 accredited radiology residencies in the United States and Canada. Survey topics included organization of the breast imaging section, residents' role in the section, clinical practice protocols of the training institution, residents' personal thoughts about breast imaging, and their interest in performing breast imaging in the future. RESULTS: Of 211 programs, 203 (96%) had dedicated breast imaging rotations; 196 (93%) rotations were 8 weeks or longer; 153 (73%), 12 weeks or longer. Residents dictated reports in 199 (94%) programs. Residents performed real-time ultrasonography (US) in 186 (88%) programs, needle localization in 199 (94%), US-guided biopsy in 174 (82%), and stereotactically guided biopsy in 181 (86%). One hundred eighty-four (87%) residents rated interpretation of mammograms more stressful than they did that of other images, and 137 (65%) believed mammograms should be interpreted by subspecialists. One hundred thirty-five (64%) residents would not consider a fellowship in breast imaging if offered, and 133 (63%) would not want to spend 25% or more of their time in clinical practice on interpretation of mammograms. The most common reasons given for not considering a fellowship or interpretation of mammograms were that breast imaging was not an interesting field, that they feared lawsuits, and that it was too stressful. Fellowships were offered at 53 programs, and at 46 programs, a total of 63 fellows were recruited. CONCLUSION: Residency training in breast imaging has improved in terms of time and curriculum. However, a majority of the residents would not consider a fellowship and did not want to interpret mammograms in their future practices.

Current status of screening mammography.

The results of RCTs conducted around the world indicate that screening mammography can substantially reduce death rates from breast cancer among women aged 40 years and over. Compelling evidence suggests that annual screening should be more effective than screening offered every 1 to 2 years. Annual screening beginning at age 40 years is now recommended by the American Cancer Society, the American Medical Association, and the American College of Radiology* Based on Swedish studies, it is likely that screening mammography can reduce breast cancer deaths by at least 50%. Screening mammography is highly cost-effective and can be performed at acceptable levels of radiation risk and rates of false-positive biopsies. By recommending screening mammography to their patients, the primary care physician can have a pivotal role in reducing the death rate from a major disease of women, similar to the effectiveness of screening for carcinoma of the cervix.