Outcomes of Breast Cancer Screening Strategies Based on Cancer Intervention and Surveillance Modeling Network Estimates.

Background There is ongoing debate about recommendations for breast cancer screening strategies, specifically regarding the frequency of screening and the age at which to initiate screening. Purpose To compare estimates of breast cancer screening outcomes published by the Cancer Intervention and Surveillance Modeling Network (CISNET) to understand the benefits and risks of different screening scenarios. Materials and Methods Modeling estimates published by CISNET are based on hypothetical cohorts in the United States and compare women, starting at 40 years of age, who do and do not undergo breast cancer screening with mammography. The four scenarios assessed in this study, of multiple possible scenarios, were biennial screening ages 50-74 years (2009 and 2016 U.S. Preventive Services Task Force [USPSTF] recommendations), biennial screening ages 40-74 years (2023 USPSTF draft recommendation), annual screening ages 40-74 years, and annual screening ages 40-79 years. For each scenario, CISNET estimates of median lifetime benefits were compared. Risks that included false-positive screening results per examination and benign biopsies per examination were also calculated and compared. Results Estimates from CISNET 2023 showed that annual screening ages 40-79 years improved breast cancer mortality reduction compared with biennial screening ages 50-74 years and biennial screening ages 40-74 years (41.7%, 25.4%, and 30%, respectively). Annual screening ages 40-79 years averted the most breast cancer deaths (11.5 per 1000) and gained the most life-years (230 per 1000) compared with other screening scenarios (range, 6.7-11.5 per 1000 and 121-230 per 1000, respectively). False-positive screening results per examination were less than 10% for all screening scenarios (range, 6.5%-9.6%) and lowest for annual screening ages 40-79 years (6.5%). Benign biopsies per examination were less than 1.33% for all screening scenarios (range, 0.88%-1.32%) and lowest for annual screening ages 40-79 years (0.88%). Conclusion CISNET 2023 modeling estimates indicate that annual breast cancer screening starting at 40 years of age provides the greatest benefit to women and the least risk per examination. © RSNA, 2024 See also the editorial by Joe in this issue.

Breast Cancer Mortality Rates Have Stopped Declining in U.S. Women Younger than 40 Years.

Background National Center for Health Statistics (NCHS) data for U.S. women have shown a steady decline in breast cancer mortality rates since 1989. Purpose To analyze U.S. breast cancer mortality rates by age decade in women aged 20-79 years and in women aged 20-39 years and women aged 40-69 years. Materials and Methods The authors conducted a retrospective analysis of (a) female breast cancer mortality rates from NCHS data for 1969-2017 for all races and by race and (b) age- and delay-adjusted invasive breast cancer incidence rates from the Surveillance, Epidemiology, and End Results program. Joinpoint analysis was used to determine trends in breast cancer mortality, invasive breast cancer incidence, and distant-stage (metastatic) breast cancer incidence rates. Results Between 1989 and 2010, breast cancer mortality rates decreased by 1.5%-3.4% per year for each age decade from 20 to 79 years (P < .001 for each). After 2010, breast cancer mortality rates continued to decline by 1.2%-2.2% per year in women in each age decade from 40 to 79 years (P < .001 for each) but stopped declining in women younger than 40 years. After 2010, breast cancer mortality rates demonstrated nonsignificant increases of 2.8% per year in women aged 20-29 years (P = .11) and 0.3% per year in women aged 30-39 years (P = .70), results attributable primarily to changes in mortality rates in White women. A contributing factor is that distant-stage breast cancer incidence rates increased by more than 4% per year after the year 2000 in women aged 20-39 years. Conclusion Female breast cancer mortality rates have stopped declining in women younger than 40 years, ending a trend that existed from 1987 to 2010. Conversely, mortality rates have continued to decline in women aged 40-79 years. Rapidly rising distant-stage breast cancer rates have likely contributed to ending the decline in mortality rates in women younger than 40 years. © RSNA, 2021 Online supplemental material is available for this article.

Digital Mammography Has Persistently Increased High-Grade and Overall DCIS Detection Without Altering Upgrade Rate.

OBJECTIVE. The purpose of this article is to evaluate whether digital mammography (DM) is associated with persistent increased detection of ductal carcinoma in situ (DCIS) or has altered the upgrade rate of DCIS to invasive cancer. MATERIALS AND METHODS. An institutional review board-approved retrospective search identified DCIS diagnosed in women with mammographic calcifications between 2001 and 2014. Ipsilateral cancer within 2 years, masses, papillary DCIS, and patients with outside imaging were excluded, yielding 484 cases. Medical records were reviewed for mammographic calcifications, technique, and pathologic diagnosis. Mammograms were interpreted by radiologists certified by the Mammography Quality Standards Act. The institution transitioned from film-screen mammography (FSM) to exclusive DM by 2010. Statistical analyses were performed using chi-square test. RESULTS. Of 484 DCIS cases, 158 (33%) were detected by FSM and 326 (67%) were detected by DM. The detection rate was higher with DM than FSM (1.4 and 0.7 per 1000, respectively; p < .001). The detection rate of high-grade DCIS doubled with DM compared with FSM (0.8 and 0.4 per 1000, respectively; p < .001). The prevalent peak of DM-detected DCIS was 2.7 per 1000 in 2008. Incident DM detection remained double FSM (1.4 vs 0.7 per 1000). Similar proportions of high-grade versus low- to intermediate-grade DCIS were detected with both modalities. There was no significant difference in the upgrade rate of DCIS to invasive cancer between DM (10%; 34/326) and FSM (10%; 15/158) (p = .74). High-grade DCIS led to 71% (35/49) of the upgrades to invasive cancer. CONCLUSION. DM was associated with a significant doubling in DCIS and high-grade DCIS detection, which persisted after prevalent peak. The majority of upgrades to invasive cancer arose from high-grade DCIS. DM was not associated with decreased upgrade to invasive cancer.

Annual Screening Mammography Associated With Lower Stage Breast Cancer Compared With Biennial Screening.

OBJECTIVE. The purpose of this study was to compare breast cancer characteristics and treatment regimens among women undergoing annual versus nonannual screening mammography. MATERIALS AND METHODS. In this retrospective, institutional review board-approved, HIPAA-compliant cohort study, a breast cancer database was queried for patients who received a mammographic or clinical diagnosis of breast cancer during 2016-2017. Annual versus biennial and annual versus nonannual (biennial and triennial) mammography screening cohorts were compared using t tests or Wilcoxon rank sum tests for continuous variables and chi-square or Fisher exact tests for categoric variables. RESULTS. A total of 490 patients were diagnosed with breast cancer during 2016-2017. Among these women, 245 had an assignable screening frequency and were 40-84 years old (mean, 61.8 ± 9.9 [SD] years; median, 62 years). Screening frequency was annual for 200 of these 245 patients (81.6%), biennial for 32 (13.1%), and triennial for 13 (5.3%). Annual screening resulted in fewer late-stage presentations (AJCC stage II, III, or IV in 48 of 200 patients undergoing annual [24.0%] vs 14 of 32 undergoing biennial [43.8%; p = .02] and vs 20 of 45 undergoing nonannual screening [44.4%; p = .006]), fewer interval cancers (21 of 200 for annual [10.5%] vs 12 of 32 for biennial [37.5%; p < .001] and vs 15 of 45 for nonannual [33.3%; p < .001]), and smaller mean tumor diameter (1.4 ± 1.2 cm for annual vs 1.8 ± 1.6 cm for biennial [p = .04] and vs 1.8 ± 1.5 cm nonannual [p = .03]). Lower AJCC stage, fewer interval cancers, and smaller tumor diameter also persisted among postmenopausal women undergoing annual screening. Patients undergoing biennial and nonannual screening showed nonsignificant greater use of axillary lymph node dissection (annual, 24 of 200 [12.0%]; biennial, 6 of 32 [18.8%]; nonannual, 7 of 45 [15.6%]) and chemotherapy (annual, 55 of 200 [27.5%]; biennial, 12 of 32 [37.5%]; nonannual, 16 of 45 [35.6%]). CONCLUSION. Annual mammographic screening was associated with lower breast cancer stage and fewer interval cancers than biennial or nonannual screening.

Digital Breast Tomosynthesis Slab Thickness: Impact on Reader Performance and Interpretation Time.

Background Digital breast tomosynthesis (DBT) helps reduce recall rates and improve cancer detection compared with two-dimensional (2D) mammography but has a longer interpretation time. Purpose To evaluate the effect of DBT slab thickness and overlap on reader performance and interpretation time in the absence of 1-mm slices. Materials and Methods In this retrospective HIPAA-compliant multireader study of DBT examinations performed between August 2013 and July 2017, four fellowship-trained breast imaging radiologists blinded to final histologic findings interpreted DBT examinations by using a standard protocol (10-mm slabs with 5-mm overlap, 1-mm slices, synthetic 2D mammogram) and an experimental protocol (6-mm slabs with 3-mm overlap, synthetic 2D mammogram) with a crossover design. Among the 122 DBT examinations, 74 mammographic findings had final histologic findings, including 31 masses (26 malignant), 20 groups of calcifications (12 malignant), 18 architectural distortions (15 malignant), and five asymmetries (two malignant). Durations of reader interpretations were recorded. Comparisons were made by using receiver operating characteristic curves for diagnostic performance and paired t tests for continuous variables. Results Among 122 women, mean age was 58.6 years ± 10.1 (standard deviation). For detection of malignancy, areas under the receiver operating characteristic curves were similar between protocols (range, 0.83-0.94 vs 0.84-0.92; P ≥ .63). Mean DBT interpretation time was shorter with the experimental protocol for three of four readers (reader 1, 5.6 minutes ± 1.7 vs 4.7 minutes ± 1.4 [P < .001]; reader 2, 2.8 minutes ± 1.1 vs 2.3 minutes ± 1.0 [P = .001]; reader 3, 3.6 minutes ± 1.4 vs 3.3 minutes ± 1.3 [P = .17]; reader 4, 4.3 minutes ± 1.0 vs 3.8 minutes ± 1.1 [P ≤ .001]), with 72% reduction in both mean number of images and mean file size (P < .001 for both). Conclusion A digital breast tomosynthesis reconstruction protocol that uses 6-mm slabs with 3-mm overlap, without 1-mm slices, had similar diagnostic performance compared with the standard protocol and led to a reduced interpretation time for three of four readers. © RSNA, 2020 See also the editorial by Chang in this issue.

Breast cancer deaths averted over 3 decades.

BACKGROUND: From 1975 to 1990, female breast cancer mortality rates in the United States increased by 0.4% per year. Since 1990, breast cancer mortality rates have fallen between 1.8% and 3.4% per year, a decrease that is attributed to increased mammography screening and improved treatment. METHODS: The authors used age-adjusted female breast cancer mortality rate and population data from the Surveillance, Epidemiology, and End Results (SEER) program to estimate the number of breast cancer deaths averted by screening mammography and improved treatment since 1989. Four different assumptions regarding background mortality rates (in the absence of screening mammography and improved treatment) were used to estimate deaths averted for women aged 40 to 84 years by taking the difference between SEER-reported mortality rates and background mortality rates for each 5-year age group, multiplied by the population for each 5-year age group. SEER data were used to estimate annual and cumulative breast cancer deaths averted in 2012 and 2015 and extrapolated SEER data were used to estimate deaths averted in 2018. RESULTS: The number of single-year breast cancer deaths averted ranged from 20,860 to 33,842 in 2012, from 23,703 to 39,415 in 2015, and from 27,083 to 45,726 in 2018. Breast cancer mortality reductions ranged from 38.6% to 50.5% in 2012, from 41.5% to 54.2% in 2015, and from 45.3% to 58.3% in 2018. Cumulative breast cancer deaths averted since 1989 ranged from 237,234 to 370,402 in 2012, from 305,934 to 483,435 in 2015, and from 384,046 to 614,484 in 2018. CONCLUSIONS: Since 1989, between 384,000 and 614,500 breast cancer deaths have been averted through the use of mammography screening and improved treatment.

Use of Screening Mammography to Detect Occult Malignancy in Autologous Breast Reconstructions: A 15-year Experience.

Purpose To examine how often screening mammography depicts clinically occult malignancy in breast reconstruction with autologous myocutaneous flaps (AMFs). Materials and Methods Between January 1, 2000, and July 15, 2015, the authors retrospectively identified 515 women who had undergone mammography of 618 AMFs and who had at least 1 year of clinical follow-up. Of the 618 AMFs, 485 (78.5%) were performed after mastectomy for cancer and 133 (21.5%) were performed after prophylactic mastectomy. Medical records were used to determine the frequency, histopathologic characteristics, presentation, time to recurrence, and detection modality of malignancy. Cancer detection rate (CDR), sensitivity, specificity, positive predictive value, and false-positive biopsy rate were calculated. Results An average of 6.7 screening mammograms (range, 1-16) were obtained over 15.5 years. The frequency of local-regional recurrence (LRR) was 3.9% (20 of 515 women; 95% confidence interval [CI]: 2.2%, 5.6%); all LRRs were invasive, and none were detected in the breast mound after prophylactic mastectomy. Of the 20 women with LRR, 13 (65%) were screened annually before the diagnosis. Seven of those 13 women (54%) had clinically occult LRR, and mammography depicted five. Five of the six clinically evident recurrences (83%) were interval cancers. The median time between reconstruction and first recurrence was 4.4 years (range, 0.8-16.2 years). The CDR per AMF was 1.5 per 1000 screening mammograms (five of 3358; 95% CI: 0.18, 2.8) after mastectomy for cancer and 0 of 1000 examinations (0 of 805 mammograms; 95% CI: 0, 5) after prophylactic mastectomy. Sensitivity, specificity, positive predictive value, and false-positive biopsy rate were 42% (five of 12), 99.4% (4125 of 4151), 16% (five of 31), and 0.6% (26 of 4151), respectively. Conclusion The CDR of screening mammography (1.5 per 1000 screening mammograms) of the AMF after mastectomy for cancer is comparable to that for one native breast of an age-matched woman. Screening mammography adds little value after prophylactic mastectomy. © RSNA, 2018.

Screening Mammography for Average-Risk Women: The Controversy and NCCN's Position.

Breast cancer remains the most common nonskin cancer among women and a leading cause of morbidity and mortality. Early detection through screening and advances in treatment have contributed to a 39% mortality reduction in the United States since 1990. The NCCN Guidelines for Breast Cancer Screening and Diagnosis recommend annual mammographic screening for average-risk women beginning at age 40 years. Mammographic screening and subsequent treatment reduces breast cancer mortality based on a wide range of studies. This article highlights NCCN's position on screening mammography and the screening controversy.

Current Issues in the Overdiagnosis and Overtreatment of Breast Cancer.

OBJECTIVE: The discovery of breast cancer at earlier stages with screening brings the risk that some cancers will be overdiagnosed or overtreated. Reasonable estimates show the overdiagnosis rate due to screening mammography to be low, 1-10%. CONCLUSION: Overdiagnosis should not be used as a reason to delay the onset or decrease the frequency of screening, because neither strategy will decrease overdiagnosis. Improvements in personalized treatment will diminish the morbidity of treatment and, therefore, the significance of overdiagnosis.

Harms of Restrictive Risk-Based Mammographic Breast Cancer Screening.

OBJECTIVE: The objective of this study was to determine if restrictive risk-based mammographic screening could miss breast cancers that population-based screening could detect. MATERIALS AND METHODS: Through a retrospective search of records at a single institution, we identified 552 screen-detected breast cancers in 533 patients. All in situ and invasive breast cancers detected at screening between January 1, 2011, and December 31, 2014, were included. Medical records were reviewed for history, pathology, cancer size, nodal status, breast density, and mammographic findings. Mammograms were interpreted by one of 14 breast imaging radiologists with 3-30 years of experience, all of whom were certified according to the Mammography Quality Standards Act. Patient ages ranged from 36 to 88 years (mean, 61 years). The breast cancer risks evaluated were family history of breast cancer and dense breast tissue. Positive family history was defined as a first-degree relative with breast cancer. Dense breast parenchyma was either heterogeneously or extremely dense. RESULTS: Group 1 consisted of the 76.7% (409/533) of patients who had no personal history of breast cancer. Of these patients, 75.6% (309/409) had no family history of breast cancer, and 56% (229/409) had nondense breasts. Group 2 consisted of the 16.7% (89/533) of patients who were 40-49 years old. Of these patients, 79.8% (71/89) had no family history of breast cancer, and 30.3% (27/89) had nondense breasts. Ductal carcinoma in situ made up 34.6% (191/552) of the cancers; 65.4% (361/552) were invasive. The median size of the invasive cancers was 11 mm. Of the screen-detected breast cancers, 63.8% (352/552) were minimal cancers. CONCLUSION: Many screen-detected breast cancers occurred in women without dense tissue or a family history of breast cancer. Exclusive use of restrictive risk-based screening could result in delayed cancer detection for many women.

Pleomorphic Lobular Carcinoma In Situ: Imaging Features, Upgrade Rate, and Clinical Outcomes.

OBJECTIVE: Pleomorphic lobular carcinoma in situ (PLCIS) is an aggressive subtype of lobular carcinoma in situ treated similarly to ductal carcinoma in situ. The purpose of this study was to determine the imaging findings, upgrade rate of PLCIS at core needle biopsy (CNB), and the treatment and outcomes of these patients. MATERIALS AND METHODS: This retrospective single-institution study included women with PLCIS at CNB or excisional biopsy without concomitant DCIS or invasive carcinoma between January 1, 1999, and July 20, 2016. Imaging findings, detection mode, treatment, and outcomes were reviewed. Retrospective review of the images was performed. Upgrade rate to ductal carcinoma in situ or invasive carcinoma at lumpectomy was calculated. RESULTS: Twenty-one patients had a finding of PLCIS at CNB (n = 16) or excisional biopsy (n = 5). Four of 15 (27%; 95% CI, 4-49%) cases of PLCIS at CNB were upgraded to DCIS (two cases) or invasive lobular cancer (two cases) at lumpectomy (one patient declined excision). No unique mammographic features were predictive of need to upgrade or extent of disease. Among the patients with pure PLCIS (not upgraded), 13 of 16 (81%) presented with fine pleomorphic calcifications on screening mammograms, 1 of 16 (6%) with distortion and calcifications, 1 of 16 (6%) with a mass, and 1 of 16 (6%) with nonmass enhancement at MRI. The median imaging size was 11 mm (mean, 14 mm; range, 3-47 mm). Twelve of 16 (75%) patients were treated with lumpectomy and 4 of 16 (25%) with mastectomy. Eight of 16 (50%) patients received adjuvant hormonal therapy, and 2 of 16 (17%) received radiation. There were no local recurrences. CONCLUSION: PLCIS most commonly presented as fine pleomorphic calcifications on mammograms and had a high upgrade rate after CNB. CNB diagnosis of PLCIS requires surgical excision.

Comparison of recommendations for screening mammography using CISNET models.

BACKGROUND: Currently, there are several different recommendations for screening mammography from major national health care organizations, including: 1) annual screening at ages 40 to 84 years; 2) screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years; and 3) biennial screening at ages 50 to 74 years. METHODS: Mean values of six Cancer Intervention and Surveillance Modeling Network (CISNET) models were used to compare these three screening mammography recommendations in terms of benefits and risks. RESULTS: Mean mortality reduction was greatest with the recommendation of annual screening at ages 40 to 84 years (39.6%), compared with the hybrid recommendation of screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years (30.8%), and the recommendation of biennial screening at ages 50 to 74 years (23.2%). For a single-year cohort of US women aged 40 years, assuming 100% compliance, more breast cancers deaths would be averted over their lifetime with annual screening starting at age 40 (29,369) than with the hybrid recommendation (22,829) or biennial screening ages 50-74 (17,153 based on 2009 CISNET estimates, 15,599 based on 2016 CISNET estimates). To achieve the greatest mortality benefit, this single-year cohort of women would have the greatest total number of screening mammograms, benign recalls, and benign biopsies performed over the course of screening by following annual screening starting at age 40 years (90.2 million, 6.8 million, and 481,269, respectively) than by following the hybrid recommendation (49.0 million, 4.1 million, and 286,288, respectively) or biennial screening at ages 50 to 74 years (27.3 million, 2.3 million, and 162,885, respectively). CONCLUSION: CISNET models demonstrate that the greatest mortality reduction is achieved with annual screening of women starting at age 40 years. Cancer 2017;123:3673-3680. © 2017 American Cancer Society.

Long-term clinical outcomes in women with breast pain in the absence of additional clinical findings: mammography remains indicated.

The purpose of the study was to determine the long-term clinical outcomes of women with breast pain in the absence of additional symptoms or signs (isolated breast pain), and the utility of mammography in their work-up. IRB approved, HIPAA compliant study retrospectively reviewed 1,386 patients referred for breast imaging with ICD-9 code for breast pain between 1/1/2006 and 12/31/2007. Of these, 617 consecutive women (mean age, 49 years) with isolated breast pain, mammogram, and follow-up (mean, 51 months) constituted the study group. Clinical data, mammographic and sonographic BI-RADS assessments, and geographic relationship between the site of cancer and pain were evaluated. The frequency of malignancies and of specific benign outcomes, both at and subsequent to the time of presentation, was determined. Breast cancer and specific benign outcomes were diagnosed in the painful breast of 11/617 (1.8 %) and 63/617 (10.2 %) women, respectively. Majority of the cancers (9/11, 81.8 %) were diagnosed subsequent (5-52 months) to initial imaging evaluation, whereas the majority of benign outcomes (52/63, 82.5 %) were diagnosed at initial presentation. Diagnostic mammography at initial presentation had a negative predictive value of 99.8 % (95 % CI 99.1 %, 100 %), specificity of 98.5 % (95 % CI 97.2 %, 99.3 %), and sensitivity of 66.7 % (95 % CI 11.6 %, 94.5 %). Three cancers were subsequently diagnosed in the contralateral (non-painful) breast. Eleven of 14 (78.6 %) cancers were in the symptomatic breast, of which 9 (81.8 %) geographically corresponded to the same area of focal pain. Thus, infrequently, breast cancer may clinically present as or be preceded by isolated breast pain and diagnostic mammography is useful for assessment.

Surgical biopsy is still necessary for BI-RADS 4 calcifications found on digital mammography that are technically too faint for stereotactic core biopsy.

The purpose of this study was to evaluate the outcome of faint BI-RADS 4 calcifications detected with digital mammography that were not amenable to stereotactic core biopsy due to suboptimal visualization. Following Institutional Review Board approval, a HIPAA compliant retrospective search identified 665 wire-localized surgical excisions of calcifications in 606 patients between 2007 and 2010. We included all patients that had surgical excision for initial diagnostic biopsy due to poor calcification visualization, whose current imaging was entirely digital and performed at our institution and who did not have a diagnosis of breast cancer within the prior 2 years. The final study population consisted of 20 wire-localized surgical biopsies in 19 patients performed instead of stereotactic core biopsy due to poor visibility of faint calcifications. Of the 20 biopsies, 4 (20% confidence intervals 2, 38%) were malignant, 5 (25%) showed atypia and 11 (55%) were benign. Of the malignant cases, two were invasive ductal carcinoma (2 and 1.5 mm), one was intermediate grade DCIS and one was low-grade DCIS. Malignant calcifications ranged from 3 to 12 mm. The breast density was scattered in 6/19 (32%), heterogeneously dense in 11/19 (58%) and extremely dense in 2/19 (10%). Digital mammography-detected faint calcifications that were not amenable to stereotactic biopsy due to suboptimal visualization had a risk of malignancy of 20%. While infrequent, these calcifications should continue to be considered suspicious and surgical biopsy recommended.

Reduction in late-stage breast cancer incidence in the mammography era: Implications for overdiagnosis of invasive cancer.

BACKGROUND: Mammographic screening is expected to decrease the incidence of late-stage breast cancer. In the current study, the authors determined the decrease in late-stage cancer incidence and the changes in invasive cancer incidence that occurred in the mammographic era after adjusting for prescreening temporal trends. METHODS: Breast cancer incidence and stage data were obtained from the Surveillance, Epidemiology, and End Results program. The premammography period (1977-1979) was compared with the mammographic screening period (2007-2009) for women aged ≥ 40 years. The authors estimated prescreening temporal trends using 5 measures of annual percentage change (APC). Stage-specific incidence values from 1977 through 1979 (baseline) were adjusted using APC values of 0.5%, 1.0%, 1.3%, and 2.0% and then compared with observed stage-specific incidence in 2007 through 2009. RESULTS: Prescreening APC temporal trend estimates ranged from 0.8% to 2.3%. The joinpoint estimate of 1.3% for women aged ≥ 40 years approximated the 4-decade long APC trend of 1.2% noted in the Connecticut Tumor Registry. At an APC of 1.3%, late-stage breast cancer incidence decreased by 37% (56 cases per 100,000 women) with a reciprocal increase in early-stage rates noted from 1977 through 1979 to 2007 through 2009. Resulting late-stage cancer incidence decreased from 21% at an APC of 0.5% to 48% at an APC of 2.0%. Total invasive breast cancer incidence decreased by 9% (27 cases per 100,000 women) at an APC of 1.3%. CONCLUSIONS: There is evidence that a substantial reduction in late-stage breast cancer has occurred in the mammography era when appropriate adjustments are made for prescreening temporal trends. At background APC estimates of ≥ 1%, the total invasive breast cancer incidence also decreased.

Digital breast tomosynthesis: observer performance of clustered microcalcification detection on breast phantom images acquired with an experimental system using variable scan angles, angular increments, and number of projection views.

PURPOSE: To investigate the dependence of microcalcification cluster detectability on tomographic scan angle, angular increment, and number of projection views acquired at digital breast tomosynthesis ( DBT digital breast tomosynthesis ). MATERIALS AND METHODS: A prototype DBT digital breast tomosynthesis system operated in step-and-shoot mode was used to image breast phantoms. Four 5-cm-thick phantoms embedded with 81 simulated microcalcification clusters of three speck sizes (subtle, medium, and obvious) were imaged by using a rhodium target and rhodium filter with 29 kV, 50 mAs, and seven acquisition protocols. Fixed angular increments were used in four protocols (denoted as scan angle, angular increment, and number of projection views, respectively: 16°, 1°, and 17; 24°, 3°, and nine; 30°, 3°, and 11; and 60°, 3°, and 21), and variable increments were used in three (40°, variable, and 13; 40°, variable, and 15; and 60°, variable, and 21). The reconstructed DBT digital breast tomosynthesis images were interpreted by six radiologists who located the microcalcification clusters and rated their conspicuity. RESULTS: The mean sensitivity for detection of subtle clusters ranged from 80% (22.5 of 28) to 96% (26.8 of 28) for the seven DBT digital breast tomosynthesis protocols; the highest sensitivity was achieved with the 16°, 1°, and 17 protocol (96%), but the difference was significant only for the 60°, 3°, and 21 protocol (80%, P < .002) and did not reach significance for the other five protocols (P = .01-.15). The mean sensitivity for detection of medium and obvious clusters ranged from 97% (28.2 of 29) to 100% (24 of 24), but the differences fell short of significance (P = .08 to >.99). The conspicuity of subtle and medium clusters with the 16°, 1°, and 17 protocol was rated higher than those with other protocols; the differences were significant for subtle clusters with the 24°, 3°, and nine protocol and for medium clusters with 24°, 3°, and nine; 30°, 3°, and 11; 60°, 3° and 21; and 60°, variable, and 21 protocols (P < .002). CONCLUSION: With imaging that did not include x-ray source motion or patient motion during acquisition of the projection views, narrow-angle DBT digital breast tomosynthesis provided higher sensitivity and conspicuity than wide-angle DBT digital breast tomosynthesis for subtle microcalcification clusters.

Implications of CISNET modeling on number needed to screen and mortality reduction with digital mammography in women 40-49 years old.

OBJECTIVE: In this article, we evaluate the implications of recent Cancer Intervention and Surveillance Modeling Network (CISNET) modeling of benefits and harms of screening to women 40-49 years old using annual digital mammography. CONCLUSION: We show that adding annual digital mammography of women 40-49 years old to biennial screening of women 50-74 years old increases lives saved by 27% and life-years gained by 47%. Annual digital mammography in women 40-49 years old saves 42% more lives and life-years than biennial digital mammography. The number needed to screen to save one life (NNS) with annual digital mammography in women 40-49 years old is 588.

Is the upgrade rate of atypical ductal hyperplasia diagnosed by core needle biopsy of calcifications different for digital and film-screen mammography?

OBJECTIVE: The purpose of this study was to establish the upgrade rate of atypical ductal hyperplasia (ADH) diagnosed by stereotactic vacuum-assisted core needle biopsy for calcifications detected by digital mammography as compared with film-screen mammography. MATERIALS AND METHODS: A retrospective record search identified 101 cases of ADH. Criteria included women with calcifications biopsied using stereotactic vacuum-assisted core needle biopsy at our institution between January 2001 and December 2011. The center transitioned from film-screen mammography in 2001 to all digital mammography by 2010. Stereotactic vacuum-assisted core needle biopsies were performed using 11-gauge (59/101 [58%]) or 8-gauge (42/101 [42%]) needles. All pathology was interpreted by breast pathologists using standard criteria. RESULTS: Of 101 cases of ADH, 57 (56.4%) were detected using digital and 44 (43.6%) were detected using film-screen mammography. Seven of 57 (12.3%) cases of ADH detected by digital mammography were upgraded to ductal carcinoma in situ (DCIS) (n = 6) or invasive cancer (n = 1). Six of 44 (13.6%) cases of ADH detected by film-screen mammography were upgraded to DCIS (n = 5) or invasive cancer (n = 1) (p = 0.84). There was a trend toward low-grade DCIS in cases detected by digital mammography (3/7 [42.9%]) as compared with film-screen mammography (1/6 [16.7%]) (p = 0.68). A nonsignificant overall higher percentage of upgrades occurred when calcifications were not completely removed (10/52 [19.2%]) as compared with completely removed (3/47 [6.4%]). There was no difference in upgrade rate of stereotactic vacuum-assisted core needle biopsy performed using 11-gauge (7/59 [11.9%]) versus 8-gauge (6/42 [14.3%]) needles. CONCLUSION: The upgrade rate of ADH diagnosed by stereotactic vacuum-assisted core needle biopsy was not significantly different between digital and film-screen mammography. The current recommendation for excision of ADH diagnosed by stereotactic vacuum-assisted core needle biopsy should be applied to ADH detected by digital mammography.