Increasing referral of at-risk women for genetic counseling and BRCA testing using a screening tool in a community breast imaging center.

BACKGROUND: Genetic evaluation and testing for hereditary breast and ovarian cancer (HBOC) remain suboptimal. The authors evaluated the feasibility of using a screening tool at a breast imaging center to increase HBOC assessment referrals. METHODS: A brief questionnaire based on the National Comprehensive Cancer Network HBOC genetic counseling referral guidelines was developed and added to the standard intake forms of patients undergoing mammography at a community breast imaging center from 2012 through 2015. Patients who met the criteria in the guidelines were referred for genetic counseling. RESULTS: A total of 34,851 patients were screened during the study period, and 1246 (4%) patients were found to be eligible for referral; 245 of these patients made a genetic counseling appointment, and 142 patients received genetic counseling. Forty patients (28%) had a personal history of breast cancer but were not previously tested. Following counseling, 105 patients were tested for BRCA1/2. Eight patients (8%) tested positive for a pathogenic mutation and nine (9%) had a variant of unknown significance. Although they tested negative, many patients met the criteria to add breast magnetic resonance imaging to their screening due to greater than 20% lifetime breast cancer risk based on their family cancer history. This study led to improved clinical risk management in 67% of the patients who underwent genetic counseling. CONCLUSIONS: This study shows that large-scale screening of patients for HBOC syndromes at time of breast imaging is practical and highly feasible. The screening tool identified women with actionable BRCA1/2 mutations and mutation-negative but high-risk women, leading to significant changes in their risk management; these women would otherwise have been missed. LAY SUMMARY: Hereditary breast and ovarian cancer (HBOC) caused by pathogenic mutations in breast cancer genes (BRCA1/BRCA2) increase an individual's lifetime risk of getting HBOC. Identifying these high-risk individuals and using proven preventive clinical risk management strategies can significantly reduce their lifetime risk of HBOC. Using an innovative family cancer history questionnaire, 34,000 women were screened at a community breast imaging center, and genetic counseling and testing were provided to eligible women from the screening. Several women at high risk for HBOC were identified and this led to positive clinical risk management changes. These women would have been missed if not for intervention.

Overutilization of Health Care Resources for Breast Pain.

OBJECTIVE: The objective of this study is to analyze the incidence of women with breast pain who present to an imaging center and assess the imaging findings, outcomes, and workup costs at breast imaging centers affiliated with one institution. MATERIALS AND METHODS: Demographic characteristics of and imaging findings for female patients presenting with breast pain at three community breast imaging centers between January 1, 2014, and December 31, 2014, were reviewed. Patients who were pregnant, were lactating, had a history of breast cancer, or presented with palpable nipple or skin findings were excluded. RESULTS: A total of 799 patients met the study criteria. Pain was diffuse in 30%, was focal in 30%, and was not localized in 40%. Of the 799 patients with breast pain, 790 (99%) presented for a diagnostic evaluation; 759 (95%) of these evaluated patients had negative findings. A benign sonographic correlate was detected in the area of pain in 5% of patients (39/799). One patient had a single cancer detected in the contralateral asymptomatic breast. When correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population (5.5 cases per 1000 examinations performed), breast pain was not found to be a sign of breast cancer (p = 0.027). Patients younger than 40 years (316/799) underwent a total of 454 workup studies for breast pain; all findings were benign, and the cost of these studies was $87,322. Patients 40 years or older (483/799) underwent 745 workup studies, for a cost of $152,732. CONCLUSION: Breast pain represents an area of overutilization of health care resources. For female patients who present with pure breast pain, breast imaging centers should consider the following imaging protocols and education for referring physicians: an annual screening mammogram should be recommended for women 40 years or older, and reassurance without imaging should be offered to patients younger than 40 years.

Implementation of breast tomosynthesis in a routine screening practice: an observational study.

OBJECTIVE: Digital mammography combined with tomosynthesis is gaining clinical acceptance, but data are limited that show its impact in the clinical environment. We assessed the changes in performance measures, if any, after the introduction of tomosynthesis systems into our clinical practice. MATERIALS AND METHODS: In this observational study, we used verified practice- and outcome-related databases to compute and compare recall rates, biopsy rates, cancer detection rates, and positive predictive values for six radiologists who interpreted screening mammography studies without (n = 13,856) and with (n = 9499) the use of tomosynthesis. Two-sided analyses (significance declared at p < 0.05) accounting for reader variability, age of participants, and whether the examination in question was a baseline were performed. RESULTS: For the group as a whole, the introduction and routine use of tomosynthesis resulted in significant observed changes in recall rates from 8.7% to 5.5% (p < 0.001), nonsignificant changes in biopsy rates from 15.2 to 13.5 per 1000 screenings (p = 0.59), and cancer detection rates from 4.0 to 5.4 per 1000 screenings (p = 0.18). The invasive cancer detection rate increased from 2.8 to 4.3 per 1000 screening examinations (p = 0.07). The positive predictive value for recalls increased from 4.7% to 10.1% (p < 0.001). CONCLUSION: The introduction of breast tomosynthesis into our practice was associated with a significant reduction in recall rates and a simultaneous increase in breast cancer detection rates.

BI-RADS-MRI: a primer.

OBJECTIVE: Variations in breast MRI techniques and descriptions of morphologic findings led to the development of a breast MRI lexicon. This lexicon, the American College of Radiology's BI-RADS-MRI, includes terminology for describing lesion architecture and enhancement characteristics. We show the use of these descriptors on breast MR images obtained at our institution. CONCLUSION: BI-RADS-MRI is a common language with which to report MRI findings of studies from different institutions.

Comparison of full-field digital mammography and screen-film mammography for detection and characterization of simulated small masses.

OBJECTIVE: The two objectives of this study were to create an ex vivo phantom model that closely mimics human breast cancer for detection tasks and to compare the performance of full-field digital mammography with screen-film mammography in detecting and characterizing small breast masses in a phantom with a spectrum of complex tissue backgrounds. MATERIALS AND METHODS: Sixteen phantom breast masses of varying sizes (0.3-1.2 cm), shapes (round and irregular), and densities (high and low) were created from shaved tumor specimens and imaged using both full-field digital and screen-film mammography techniques. We created 408 detection tasks that were captured on 68 films. On each radiograph, six detection tasks were partially obscured by areas of varying breast-pattern complexity, including low (predominantly fatty), mixed (scattered fibroglandular densities and heterogeneously dense), and high (extremely dense) density patterns. Each detection task was scored using a five-point confidence scale by three mammographers. Receiver operating characteristic (ROC) curve analysis was performed to analyze differences in detection of masses between the two imaging systems, and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were computed. RESULTS: Full-field digital mammography showed higher area under the ROC curve than screen-film mammography for detecting masses in each breast background and performed significantly better than screen-film mammography in mixed (p = 0.010), dense (p = 0.029), and all breast backgrounds combined (p = 0.004). Full-field digital mammography was superior to screen-film mammography for characterizing round and irregular masses and low- and high-density masses. CONCLUSION: Full-field digital mammography was significantly superior to screen-film technique for detecting and characterizing small masses in mixed and dense breast backgrounds in a phantom model.

Mammographic-pathologic correlation of apocrine metaplasia diagnosed using vacuum-assisted stereotactic core-needle biopsy: our 4-year experience.

OBJECTIVE: To determine whether focal apocrine metaplasia of the breast has distinctive mammographic characteristics, we evaluated apocrine metaplasia diagnosed by vacuum-assisted stereotactic core-needle biopsy and correlated mammographic imaging and histopathologic findings. MATERIALS AND METHODS: We retrospectively reviewed our institutional database for records of all vacuum-assisted stereotactic core-needle biopsies performed during a 4-year period. Five hundred thirty-eight lesions were biopsied, of which 302 (56%) were benign. Apocrine metaplasia was diagnosed in 37 lesions. In 11 of these 37 lesions, apocrine metaplasia made up more than 50% of the lesion sampled. RESULTS: On mammography, eight cases (73%) appeared as new or increasing calcifications, and three cases (27%) appeared as new or enlarging equal-density masses (0.6-1.2 cm). Calcifications were heterogeneous in five lesions (63%), amorphous in two (25%), and punctate in one (12%); one heterogeneous cluster of calcifications (12%) also contained milk of calcium. The pattern of calcification distribution was clustered in five lesions (63%), multiple clusters in two (25%), and linear in one (12%). Two masses (67%) were lobular, and one (33%) was round. Two borders (67%) were microlobulated, and one (33%) was circumscribed. CONCLUSION: Apocrine metaplasia is a benign condition commonly associated with other fibrocystic changes. Lesions composed of more than 50% focal apocrine metaplasia are relatively uncommon. A new or enlarging lobular, microlobulated mass or heterogeneous calcification cluster may represent apocrine metaplasia. Because no distinguishing mammographic features are present to require follow-up by imaging, needle biopsy is required for definitive diagnosis.

Needle localization for excisional biopsy of breast lesions: comparison of effect of use of full-field digital versus screen-film mammographic guidance on procedure time.

The time required to perform needle localization with full-field digital (FFD) mammography was compared with the time required to perform it with screen-film (SF) mammography in 158 women with breast lesions. The time needed to position the patient before the first image was acquired, needle placement time, and total procedure time were compared between techniques. Regression modeling was performed to assess the effect of mammographic guidance method while simultaneously adjusting for other significant covariates. By using the backward selection technique, statistically nonsignificant variables were removed one at a time to produce a final model for which all statistically significant effects were defined as those with P <.10. Total procedure time for all lesions was shorter with FFD than with SF mammography. The time needed to position the patient and needle placement time were also significantly shorter with FFD than with SF mammography. Procedure time for needle localization of breast lesions is significantly shorter with FFD than with SF mammographic guidance.