Predicting Upgrade of Ductal Carcinoma In Situ to Invasive Breast Cancer at Surgery With Ultrafast Imaging.

BACKGROUND. Biopsy-proven ductal carcinoma in situ (DCIS) lesions are often upgraded to invasive cancer at surgery. Therefore, accurate prediction of the likelihood of invasion is helpful for surgical planning, including the need for sentinel lymph node biopsy (SLNB). OBJECTIVE. The purpose of the present study was to investigate whether kinetic features of clinically available ultrafast MRI (UF-MRI) can predict upgrade of biopsy-proven DCIS to invasive cancer at surgical excision. METHODS. Consecutive patients with biopsy-proven pure DCIS lesions who underwent UF-MRI with conventional dynamic contrast-enhanced MRI (DCE-MRI) and subsequently underwent surgery between August 2019 and January 2021 were identified. Patient and lesion characteristics, biopsy method and pathology, and lesion features on mammography, ultrasound, DCE-MRI, and UF-MRI were assessed to determine predictors of upgrade to invasive cancer. The Fisher exact test and Kruskal-Wallis test were used for association analysis. RESULTS. In 68 patients (median age, 52.0 years; range, 31-79 years) with 68 biopsy-proven pure DCIS lesions, 26 lesions (38%) were upgraded from in situ to invasive cancer. An upgrade of DCIS to invasive cancer was significantly associated with a shorter time to enhancement (TTE) on preoperative UF-MRI (p = .03), with a threshold of 11 seconds providing maximum specificity (50%) and sensitivity (76%) for upgrade. Larger lesion size on DCE-MRI (p = .001) and mammography (p = .04) was also significantly associated with upgrade; an optimal predictive threshold of 4.4 cm on DCE-MRI yielded sensitivity of 88% and specificity of 56%. No other specific variables were significantly associated with upgrade after surgery. Logistic regression of selected features combined with TTE produced a higher AUC (0.85) in predicting upgrade to invasive disease than did each factor alone, but this result was not statistically significant. CONCLUSION. Preoperative UF-MRI TTE and lesion size on DCE-MRI and mammography show potential in predicting upgrade of DCIS to invasive cancer at surgery. CLINICAL IMPACT. UF-MRI provides useful information that can be used in surgical planning, including determination of the need to perform SLNB.

Update on Lobular Neoplasia.

Lobular neoplasia (LN) is a histopathologic entity that encompasses both lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). Management of LN is known to be variable and institutionally dependent. The variability in approach after a diagnosis of LN at percutaneous breast biopsy derives in part from heterogeneity in the literature, resulting in a range of reported upgrade rates to malignancy after initial identification at percutaneous biopsy, and also from historical shifts in understanding of the natural history of LN. It has become increasingly recognized that not all LN is the same and that distinct variants of LN such as pleomorphic LCIS and florid LCIS have distinct natural histories and distinct likelihoods of upgrade to malignancy. In addition, it is also increasingly understood that appropriate management of LN relies on scrupulous radiologic-pathologic correlation. This review details the imaging features and histopathologic nature of ALH, classic-type LCIS, and the LCIS variants; addresses changes in the historical understanding of this entity contributing to confusion regarding its management; and discusses the importance of performing radiologic-pathologic correlation after percutaneous biopsy to help guide appropriate management steps when LN is encountered. In addition to the short-term implications of an LN diagnosis in terms of upgrade and surgical outcomes, the long-term implications of an LN diagnosis regarding risk of developing a later breast cancer are examined. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Breast Cancer Screening in Survivors of Childhood Cancer.

Women who survived childhood cancers or cancers at a young age are at high risk for breast cancer later in life. The accentuated risk is notable among those treated at a young age with a high radiation dose but also extends to survivors treated with therapies other than or in addition to radiation therapy. The predisposing risk factors are complex. Advances in radiation therapy continue to curtail exposure, yet the risk of a second cancer has no dose threshold and a long latency period, and concurrent use of chemotherapy may have an additive effect on long-term risk of cancer. Early screening with annual mammography and MRI is recommended for chest radiation exposure of 10 Gy or greater, beginning 8 years after treatment or at age 25 years, whichever is later. However, there is a lack of recommendations for those at high risk without a history of radiation therapy. Because mortality after breast cancer among survivors is higher than in women with de novo breast cancer, and because there is a higher incidence of a second asynchronous breast cancer in survivors than that in the general population, regular screening is essential and is expected to improve mortality. However, awareness and continuity of care may be lacking in these young patients and is reflected in their poor screening attendance. The transition of care from childhood to adulthood for survivors requires age-targeted and lifelong strategies of education and risk prevention that are needed to improve long-term outcomes for these patients. © RSNA, 2023 See the invited commentary by Chikarmane in this issue. Quiz questions for this article are available through the Online Learning Center.

New Horizons: Artificial Intelligence for Digital Breast Tomosynthesis.

The use of digital breast tomosynthesis (DBT) in breast cancer screening has become widely accepted, facilitating increased cancer detection and lower recall rates compared with those achieved by using full-field digital mammography (DM). However, the use of DBT, as compared with DM, raises new challenges, including a larger number of acquired images and thus longer interpretation times. While most current artificial intelligence (AI) applications are developed for DM, there are multiple potential opportunities for AI to augment the benefits of DBT. During the diagnostic steps of lesion detection, characterization, and classification, AI algorithms may not only assist in the detection of indeterminate or suspicious findings but also aid in predicting the likelihood of malignancy for a particular lesion. During image acquisition and processing, AI algorithms may help reduce radiation dose and improve lesion conspicuity on synthetic two-dimensional DM images. The use of AI algorithms may also improve workflow efficiency and decrease the radiologist's interpretation time. There has been significant growth in research that applies AI to DBT, with several algorithms approved by the U.S. Food and Drug Administration for clinical implementation. Further development of AI models for DBT has the potential to lead to improved practice efficiency and ultimately improved patient health outcomes of breast cancer screening and diagnostic evaluation. See the invited commentary by Bahl in this issue. ©RSNA, 2022.

Multiple Bilateral Circumscribed Masses at Screening Breast Ultrasound: Outcomes of New or Enlarging Masses at Follow-Up.

BACKGROUND. Breast screening ultrasound (US) has limited specificity but is increasingly performed because of widening state and federal legislation regarding breast density. There is a need for evidence-based management guidelines. OBJECTIVE. The purpose of this study was to assess outcomes of new or enlarging oval circumscribed parallel masses in the setting of multiple bilateral circumscribed masses (MBCM) at sequential rounds of US screening. METHODS. In this retrospective study of women found to have MBCM on screening breast US without mammography abnormalities, longitudinal review was performed to identify development of any new or enlarging or changing masses. Outcomes were recorded using biopsy results or minimum of 12 months of follow-up as reference standards. Lesion characteristics, BI-RADS classification, breast density, patient age, demographics, and risk factors were reviewed. Statistical analysis included multivariable logistic regression analysis. RESULTS. There were 284 (2.4%) cases of MBCM in a total of 48,488 bilateral screening US examinations performed in 11,826 asymptomatic women between January 1, 2014, and July 31, 2019, that fit inclusion criteria. Of the 284 women (mean age, 46 years; range, 20-83 years), 150 (52.8%) subsequently developed 465 new, enlarging, and/or changing masses, 107 (23.0%) of which underwent biopsy. Of the 465 masses, 408 (87.7%) were oval circumscribed parallel masses and similar to other MBCM, and 57 (12.3%) were unique findings that were nonoval noncircumscribed masses. None of the new or enlarging oval circumscribed parallel masses were malignant. In total, the malignancy rate was 0% for women with MBCM with follow-up (median, 40.8 months; range, 12-75 months) and 0% for those that underwent biopsy (95% CI, 0-1.2%). Among women with concurrent MBCM and unique findings, four cancers were detected. Three were new irregular masses, and one previously oval mass changed in morphology to have new calcifications and an irregular border. A younger age was related to the likelihood of having enlarging masses (p < .001). CONCLUSION. In the setting of MBCM, new or enlarging oval circumscribed parallel masses are a common and benign event. Concurrent new irregular masses or previously oval masses that develop suspicious morphologic features should be carefully evaluated for malignancy. CLINICAL IMPACT. Breast radiologists who encounter new or enlarging oval circumscribed parallel masses with no suspicious morphologic change in the setting of MBCM can safely defer biopsies.

Health Disparity and Breast Cancer Outcomes in Asian Women.

Health disparities in Asian women are complex and multifactorial. Screening attendance is low among Asian women, regardless of nativity or acculturation, and breast cancer detection has decreased by more than half in this population during the COVID-19 pandemic. The follow-up rate after abnormal screening results is similarly poor among Asian women compared with that among other groups, often resulting in a delay of cancer diagnosis. Yet the incidence of breast cancer in Asian women is increasing in the United States, with no such increase observed in other racial and ethnic groups in recent years. The age distribution of breast cancer in Asian women is distinct and peaks in younger women, underscoring the importance of early screening. The predilection for human epidermal growth factor receptor 2 (HER2)-enriched tumors may reflect the unique biologic characteristics of breast cancer among Asian subgroups, which are not well understood. Known biomarkers for breast cancer risk such as body mass index and mammographic density do not perform the same way in Asian women, as compared with other groups, owing to a lack of Asian population-specific data. Within that limitation, the association between body mass index and breast cancer is strongest in older Asian women, and the association between breast density and breast cancer is strongest in younger Asian women. There is an unmet need to improve breast cancer care in Asian women, a heterogeneous and growing population that is facing an increasing burden of breast cancer. An invited commentary by Leung is available online. ©RSNA, 2022.

Non-BRCA Early-Onset Breast Cancer in Young Women.

The incidence of breast cancer in younger women is rising. Although early-onset breast cancer is highly associated with biologically aggressive tumors such as triple-negative and human epidermal growth factor 2 (HER2)-positive cancers, the more recent increase is disproportionately driven by an increase in the incidence of luminal cancer. In particular, the increase in de novo stage IV disease and the inherent age-based poorer survival rate among younger women with even early-stage luminal cancers suggest underlying distinct biologic characteristics that are not well understood. Further contributing to the higher number of early-onset breast cancers is pregnancy-associated breast cancer (PABC), which is attributed to persistent increases in maternal age over time. Although guidelines for screening of patients who carry a BRCA1 or BRCA2 gene mutation are well established, this population comprises only a fraction of those with early-onset breast cancer. A lack of screening in most young patients precludes timely diagnosis, underscoring the importance of early education and awareness. The disproportionate disease burden in young women of certain racial and ethnic groups, which is further exacerbated by socioeconomic disparity in health care, results in worse outcomes. An invited commentary by Monticciolo is available online. ©RSNA, 2022.

Digital Breast Tomosynthesis: Update on Technology, Evidence, and Clinical Practice.

Digital breast tomosynthesis (DBT) has been widely adopted in breast imaging in both screening and diagnostic settings. The benefits of DBT are well established. Compared with two-dimensional digital mammography (DM), DBT preferentially increases detection of invasive cancers without increased detection of in-situ cancers, maximizing identification of biologically significant disease, while mitigating overdiagnosis. The higher sensitivity of DBT for architectural distortion allows increased diagnosis of invasive cancers overall and particularly improves the visibility of invasive lobular cancers. Implementation of DBT has decreased the number of recalls for false-positive findings at screening, contributing to improved specificity at diagnostic evaluation. Integration of DBT in diagnostic examinations has also resulted in an increased percentage of biopsies with positive results, improving diagnostic confidence. Although individual DBT examinations have a longer interpretation time compared with that for DM, DBT has streamlined the diagnostic workflow and minimized the need for short-term follow-up examinations, redistributing much-needed time resources to screening. Yet DBT has limitations. Although improvements in cancer detection and recall rates are seen for patients in a large spectrum of age groups and breast density categories, these benefits are minimal in women with extremely dense breast tissue, and the extent of these benefits may vary by practice environment and by geographic location. Although DBT allows detection of more invasive cancers than does DM, its incremental yield is lower than that of US and MRI. Current understanding of the biologic profile of DBT-detected cancers is limited. Whether DBT improves breast cancer-specific mortality remains a key question that requires further investigation. ©RSNA, 2021.

Breast MRI for Evaluation of Response to Neoadjuvant Therapy.

Neoadjuvant therapy is increasingly being used to treat early-stage triple-negative and human epidermal growth factor 2-overexpressing breast cancers, as well as locally advanced and inflammatory breast cancers. The rationales for neoadjuvant therapy are to shrink tumor size and potentially decrease the extent of surgery, to serve as an in vivo test of response to therapy, and to reveal prognostic information for the patient. MRI is the most accurate modality to demonstrate response to therapy and to help ensure accurate presurgical planning. Changes in lesion diameter, volume, and enhancement are used to predict complete response, partial response, or nonresponse to therapy. However, residual disease may be overestimated or underestimated at MRI. Fibrosis, necrotic tumors, and residual benign masses may be causes of overestimation of residual disease. Nonmass lesions, invasive lobular carcinoma, hormone receptor-positive tumors, nonconcentric shrinkage patterns, the use of antiangiogenic therapy, and late-enhancing foci may be causes of underestimation of residual disease. In patients with known axillary lymph node metastasis, neoadjuvant therapy may be followed by targeted axillary dissection to avoid the potential morbidity associated with an axillary lymph node dissection. Diffusion-weighted imaging, radiomics, machine learning, and deep learning methods are under investigation to improve MRI accuracy in predicting treatment response.©RSNA, 2021.

Abbreviated and Ultrafast Breast MRI in Clinical Practice.

Abbreviated and ultrafast breast MRI are emerging techniques that are now entering clinical practice and reflect an increasing understanding of breast cancer heterogeneity. These techniques may represent potential answers to shortcomings of mammographic screening, providing an opportunity to curb interval cancers, maximize diagnostic accuracy, and minimize overdiagnosis. Targeting more aggressive tumor subtypes may play a role in evidence-based de-escalation of breast cancer management, and abbreviated techniques have proved promising in early noninferiority studies. Functional characterization of tumors at MRI also has the potential for noninvasive tumor subtyping based on radiomics and radiogenomics and may ultimately streamline increasingly individualized breast cancer care. The purpose of this article is to describe techniques of abbreviated and ultrafast breast MRI, recognize their pros and cons, and discuss clinical applications and implications. The goals are to define terminology, consider diagnostic parameters, and emphasize key concepts. As these novel techniques enter clinical care and continue to evolve, it is essential that the radiologist understands the rationale and limitations behind these approaches and how and why interpretation may differ from that of conventional MRI. ©RSNA, 2020.

Breast Imaging in Transgender Patients: What the Radiologist Should Know.

Transgender is the umbrella term for individuals whose gender identity and/or gender expression differs from their assigned sex at birth. With the rise in patients undergoing gender-affirming hormone therapy and gender-affirming surgery, it is increasingly important for radiologists to be aware of breast imaging considerations for this population. While diagnostic imaging protocols for transgender individuals are generally similar to those for cisgender women, screening guidelines are more variable. Currently, several professional and institutional guidelines have been created to address breast cancer screening in the transgender population, specifically screening mammography in transfeminine individuals who undergo hormone therapy. This article defines appropriate terminology with respect to the transgender population, reviews evidence for breast cancer risk and screening in transgender individuals, considers diagnostic breast imaging approaches, and discusses special considerations and challenges with regard to health care access and public education for these individuals. ©RSNA, 2019.

City Patterns of Screening Mammography Uptake and Disparity across the United States.

Background Although previous studies have focused on rural disparities in the use of screening mammography, city-level use throughout the United States has not been well evaluated even though more than 30 million women live in the 500 largest cities. Purpose To evaluate disparities in the city-level use of screening mammography and to identify factors that have an impact on screening utilization. Materials and Methods This retrospective study used data from large publicly available databases, the American Community Survey and Robert Wood Johnson Foundation 500 Cities Project, which includes screening mammography utilization data from the Behavioral Risk Factor Surveillance System. Databases were searched from January to March 2018. The use of screening mammography was evaluated at the city level by census region and division by using the Mann-Whitney U test. Univariable Spearman rank correlation and multivariable regression analysis were performed to determine the impact of factors on screening use, including population size, health-related variables (use of Papanicolaou test, obesity), income variables (median household income, poverty status, health insurance), and race. Results Overall mean city-level screening mammography use rate was 77.7% (range, 62.8%-88.9%). The highest mean utilization occurred in coastal cities, with the highest overall utilization in the New England area (82.7%). The lowest utilization rate was in Mountain states (73.6%). City-level utilization showed a positive correlation with Papanicolaou test use (r = 0.75, P < .001), median household income (r = 0.44, P < .001), and percentage Asian population (r = 0.38, P < .001) and a negative correlation with obesity (r = -0.36, P < .001), the lack of health insurance (r = -0.44, P < .001), and poverty (r = -0.30, P < .001). Multivariable analysis showed the strongest independent predictors of utilization to be percentage of women screened with the Papanicolaou test, Asian race, private insurance, and census division (R2 = 68%). Conclusion Disparities in the utilization of preventive health care services exist at the large city level, with the highest use in New England cities and lowest in Mountain cities. Predictors of higher than average utilization include census division and percentage of inhabitants who are up to date with the Papanicolaou test, are of Asian race, and have private insurance. © RSNA, 2019.

Breast Cancer Screening in High-Risk Men: A 12-year Longitudinal Observational Study of Male Breast Imaging Utilization and Outcomes.

Background Male breast cancer incidence is rising. There may be a potential role in selective screening in men at elevated risk for breast cancer, but the effectiveness of such screening remains unexplored. Purpose To evaluate patterns of male breast imaging utilization, to determine high-risk screening outcomes, and to delineate risk factors associated with cancer diagnosis. Materials and Methods This retrospective study reviewed consecutive male breast imaging examinations over a 12-year period (between 2005-2017). Examination indications, biopsy recommendations, and pathologic results were correlated with patient characteristics. Fisher exact test, Mann-Whitney test, Spearman correlation, and logistic regression were used for statistical analysis. Results A total of 1869 men (median age, 55 years; range, 18-96 years) underwent 2052 examinations yielding 2304 breast lesions and resulting in 149 (6.5%) biopsies in 133 men; 41 (27.5%) were malignant and 108 (72.5%) were benign. There were 1781 (86.8%) diagnostic and 271 (13.2%) screening examinations. All men undergoing screening had personal or family history of breast cancer and/or genetic mutations. There was a significant increase in the number of examinations in men relative to the number of examinations in women over time (Spearman correlation, r = 0.85; P < .001). Five node-negative cancers resulted from screening mammography, yielding a cancer detection rate of 18 per 1000 examinations (95% confidence interval [CI]: 7, 41), with cancers diagnosed on average after 4 person-years of screening (range, 1-10 person-years). Mammographic screening sensitivity, specificity, and positive predictive value of biopsy were 100% (95% CI: 50%, 100%), 95.0% (95% CI: 93.1%, 98%), and 50% (95% CI: 22.2%, 77.8%). Older age (P < .001), Ashkenazi descent (P < .001), genetic mutations (P = .006), personal history (P < .001), and first-degree family history (P = .03) were associated with breast cancer. Non-first-degree family history was not associated with cancer (P = .09). Conclusion There is potential benefit in screening men at high risk for developing breast cancer. Such screening may have increased over time. © RSNA, 2019.

MRI breast screening revisited.

Contrast-enhanced breast MRI is a standard evidence-based component of supplemental screening in conjunction with mammography for higher-risk populations because of its high sensitivity for detecting breast cancer; the use of breast MRI for screening in high-risk populations is recommended in multiple national and international guidelines. The current MRI exam, however, is expensive relative to other screening technologies such as mammography, and relatively more time-intensive. Recent investigations have focused on techniques that have the potential for improving efficiency of the breast MRI exam, decreasing acquisition and reading times, without impacting diagnostic accuracy. The purpose of this article is therefore to provide an overview of current MRI guidelines for screening for breast cancer and to discuss evolving technological approaches to breast MRI, in particular abbreviated and ultrafast MRI protocols, as well as MRI protocols without contrast that have the potential to improve MRI screening. Level of Evidence: 5 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019;49:1212-1221.

Overstated Harms of Breast Cancer Screening? A Large Outcomes Analysis of Complications Associated With 9-Gauge Stereotactic Vacuum-Assisted Breast Biopsy.

OBJECTIVE: The purpose of this study was to assess the rate, type, and severity of complications related to 9-gauge stereotactic vacuum-assisted breast biopsy (SVAB) and to delineate associated factors that may contribute to a higher rate of complications. MATERIALS AND METHODS: This retrospective study included 4776 patients who underwent SVAB between 2003 and 2016. A total of 319 patients with documented postbiopsy complications were identified. Complications were subcategorized as bleeding, pain, lightheadedness, bruising, and other complications, and their severity was classified as minor, moderate, or severe. Hematoma volumes were correlated with biopsy location and complication severity. A group of control subjects who underwent SVAB but had no complications was compared with the group of study patients with regard to age, biopsy location, lesion type, and pathologic findings. Postbiopsy screening adherence was assessed. Statistical analyses were performed using the Fisher exact, Mann-Whitney, Kruskal-Wallis, and Spearman rank correlation tests. RESULTS: Of the 319 patients with complications who were identified (representing 6.7% of the 4776 patients who underwent SVAB), 307 (96.2%) had mild complications, 12 (3.8%) had moderate complications, and no patients had severe complications. The most common complication was bleeding or hematoma (89.3% of patients [285/319]), followed by pain (6.9% [22/319]), lightheadedness (0.9% [3/319]), bruising (0.9% [3/319]), and other complications (1.9% [6/319]). No significant differences were noted between the study group and the control group in terms of age (p = 0.474), biopsy location (p = 0.065), histologic findings (p = 0.056), or lesion type (p = 0.568). Hematoma volume (median, 7.5 cm3) did not correspond to the severity of complications. Larger hematoma volumes were associated with a posterior biopsy location (p = 0.008). The rate of return to annual screening after biopsy was not adversely affected by the presence of biopsy complications. CONCLUSION: Clinically significant complications associated with SVAB were exceedingly rare (0.3%) in this large study spanning 13 years.

An Analysis of Nipple Enhancement at Breast MRI with Radiologic-Pathologic Correlation.

Breast MRI is the most sensitive imaging modality for assessment of the nipple-areola complex (NAC), which is important both in cancer staging and in high-risk screening. However, the normal appearance of the nipple at MRI is not well defined because of a paucity of scientific literature on this topic. Hence, there is a lack of descriptive terminology and diagnostic criteria, which may account for the wide variability in interpretation among radiologists when assessing the NAC on MR images. In light of the current shift toward possible expanded use of abbreviated (ie, fast) breast MRI for screening in women at average risk for cancer in particular, and because an increasing number of women now undergo nipple-sparing mastectomy for therapeutic and/or prophylactic indications, careful assessment of the NAC at MRI is essential. In this article, the normal pattern of nipple enhancement at MRI is defined on the basis of findings observed in healthy individuals, normal nipple enhancement at MRI is correlated with the structural anatomy of the nipple at histopathologic analysis, and artifacts and pitfalls related to MRI of the NAC are reviewed. Understanding the normal range of nipple morphology and enhancement at MRI is important, as it enables radiologists to better differentiate between normal and abnormal nipple findings with increased diagnostic confidence. ©RSNA, 2018 See discussion on this article by Cohen and Holbrook .

Use of Breast Cancer Screening and Its Association with Later Use of Preventive Services among Medicare Beneficiaries.

Purpose To retrospectively assess whether there is an association between screening mammography and the use of a variety of preventive services in women who are enrolled in Medicare. Materials and Methods U.S. Medicare claims from 2010 to 2014 Research Identifiable Files were reviewed to retrospectively identify a group of women who underwent screening mammography and a control group without screening mammography in 2012. The screened group was divided into positive versus negative results at screening, and the positive subgroup was divided into false-positive and true-positive findings. Multivariate logistic regression models and inverse probability of treatment weighting were used to examine the relationship between screening status and the probabilities of undergoing Papanicolaou test, bone mass measurement, or influenza vaccination in the following 2 years. Results The cohort consisted of 555 705 patients, of whom 185 625 (33.4%) underwent mammography. After adjusting for patient demographics, comorbidities, geographic covariates, and baseline preventive care, women who underwent index screening mammography (with either positive or negative results) were more likely than unscreened women to later undergo Papanicolaou test (odds ratio [OR], 1.49; 95% confidence interval: 1.40, 1.58), bone mass measurement (OR, 1.70; 95% confidence interval: 1.63, 1.78), and influenza vaccine (OR, 1.45; 95% confidence interval: 1.37, 1.53). In women who had not undergone these preventive measures in the 2 years before screening mammography, use of these three services after false-positive findings at screening was no different than after true-negative findings at screening. Conclusion In beneficiaries of U.S. Medicare, use of screening mammography was associated with higher likelihood of adherence to other preventive guidelines, without a negative association between false-positive results and cervical cancer screening.

What Happens after a Diagnosis of High-Risk Breast Lesion at Stereotactic Vacuum-assisted Biopsy? An Observational Study of Postdiagnosis Management and Imaging Adherence.

Purpose To assess adherence with annual or biennial screening mammography after a diagnosis of high-risk lesion(s) at stereotactic biopsy with or without surgical excision and to identify clinical factors that may affect screening adherence after a high-risk diagnosis. Materials and Methods This institutional review board-approved HIPAA-compliant retrospective study included 208 patients who underwent stereotactic biopsy between January 2012 and December 2014 that revealed a high-risk lesion. Whether the patient underwent surgical excision and/or follow-up mammography was documented. Adherence of these women to a protocol of subsequent mammography within 1 year (9-18 months) or within 2 years (9-30 months) was compared with that of 45 508 women with normal screening mammograms who were imaged during the same time period at the same institution. Possible factors relevant to postdiagnosis management and screening adherence were assessed. Consultation with a breast surgeon was identified by reviewing clinical notes. Uptake of pharmacologic chemoprevention following diagnosis (patient decision to take chemopreventive medications) was assessed. The Fisher exact test was used to compare annual or biennial screening adherence rates. Binary logistic regression was used to identify factors predictive of whether women returned for screening within selected time frames. Results In total, 913 (1.3%) of 67 874 women were given a recommendation to undergo stereotactic biopsy, resulting in diagnosis of 208 (22.8%) of 913 high-risk lesions. Excluding those with a prior personal history of breast cancer or upgrade to cancer at surgery, 124 (66.7%) of 186 women underwent surgery and 62 (33.3%) did not. Overall post-high-risk diagnosis adherence to annual or biennial mammography was similar to that in control subjects (annual, 56.4% vs 50.8%, P = .160; biennial, 62.0% vs 60.1%, P = .630). Adherence was significantly better in the surgical group than in the nonsurgical group for annual mammography (70.0% vs 32.0%; odds ratio [OR] = 5.0; 95% confidence interval [CI]: 2.4, 10.1; P < .001) and for biennial mammography (74.3% vs 40.0%; OR = 4.3; 95% CI: 2.1, 8.8; P < .001). Among the patients in the nonsurgical group, those adherent to annual or biennial mammography were significantly more likely to have seen a breast surgeon than the nonadherent women (annual, 77.3% vs 35.7%, P = .005; biennial, 67.9% vs 36.4%, P = .045). All patients receiving chemopreventive agents underwent a surgical consultation (100%; n = 21). Conclusion Although diagnosis of a high-risk lesion at stereotactic breast biopsy did not compromise overall adherence to subsequent mammographic screening, patients without surgical excision, particularly those who did not undergo a surgical consultation, had significantly lower imaging adherence and chemoprevention uptake as compared with their counterparts who underwent surgery, suggesting that specialist care may be important in optimizing management. © RSNA, 2018.

Feasibility analysis of early temporal kinetics as a surrogate marker for breast tumor type, grade, and aggressiveness.

BACKGROUND: Screening breast MRI has been shown to preferentially detect high-grade ductal carcinoma in situ (DCIS) and invasive carcinoma, likely due to increased angiogenesis resulting in early initial uptake of contrast. As interest grows in abbreviated screening breast MRI (AB-MRI), markers of early contrast washin that can predict tumor grade and potential aggressiveness are of clinical interest. PURPOSE: To evaluate the feasibility of using the initial enhancement ratio (IER) as a surrogate marker for tumor grade, hormone receptor status, and prognostic markers, as an initial step to being incorporated into AB-MRI. STUDY TYPE: Retrospective. SUBJECTS: In all, 162 women (mean 55.0 years, range 32.8-87.7 years) with 187 malignancies imaged January 2012-November 2015. FIELD STRENGTH/SEQUENCE: Images were acquired at 3.0T with a T1 -weighted gradient echo fat-suppressed-volume interpolated breath-hold sequence. ASSESSMENT: Subjects underwent dynamic contrast-enhanced breast MRI with a 7-channel breast coil. IER (% signal increase over baseline at the first postcontrast acquisition) was assessed and correlated with background parenchymal enhancement, washout curves, stage, and final pathology. STATISTICAL TESTS: Chi-square test, Spearman rank correlation, Mann-Whitney U-tests, Bland-Altman analysis, and receiver operating characteristic curve analysis. RESULTS: IER was higher for invasive cancer than for DCIS (R1/R2, P < 0.001). IER increased with tumor grade (R1: r = 0.56, P < 0.001, R2: r = 0.50, P < 0.001), as ki-67 increased (R1: r = 0.35, P < 0.001; R2 r = 0.35, P < 0.001), and for node-positive disease (R1/R2, P = 0.001). IER was higher for human epidermal growth factor receptor two-positive and triple negative cancers than for estrogen receptor-positive / progesterone receptor-positive tumors (R1 P < 0.001-0.002; R2 P = 0.0.001-0.011). IER had higher sensitivity (80.6% vs. 75.5%) and specificity (55.8% vs. 48.1%) than washout curves for positive nodes, higher specificity (48.1% vs. 36.5%) and positive predictive value (70.2% vs. 66.7%) for high ki-67, and excellent interobserver agreement (intraclass correlation coefficient = 0.82). DATA CONCLUSION: IER, a measurement of early contrast washin, is associated with higher-grade malignancies and tumor aggressiveness and might be potentially incorporated into an AB-MRI protocol. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1692-1700.

County-Level Factors Predicting Low Uptake of Screening Mammography.

OBJECTIVE: The purpose of this study was to investigate county-level geographic patterns of mammographic screening uptake throughout the United States and to determine the impact of rural versus urban settings on breast cancer screening uptake. MATERIALS AND METHODS: This descriptive study used County Health Rankings data to identify the percentage of Medicare enrollees 67-69 years old per county who had at least one mammogram in 2013 or 2012 (uptake). Uptake was matched with U.S. Department of Agriculture Atlas of Rural and Small Town America categorizations along a rural-urban continuum scale from 1 to 9 based on county population size (large urban, population ≥ 20,000 people; small urban, < 20,000 people) and proximity to a metropolitan area. Univariable and multivariable analyses were performed. RESULTS: In all, 2,243,294 Medicare beneficiaries were eligible for mammograms. National mean uptake per county was 60.5% (range, 26.0-86.0%). Uptake was significantly higher in metropolitan and large urban counties in 25 states and lower in only one. County-level mammographic uptake was moderately positively correlated with percentage of residents with some college education (r = 0.40, p < 0.001) and moderately negatively correlated with age-adjusted mortality (r = -0.41, p < 0.001). Multivariable analysis showed that percentage of white and black residents and age-adjusted mortality rate were the strongest significant independent predictors of uptake. CONCLUSION: Uptake of mammographic screening services in a Medicare population varies widely at the county level and is generally lowest in rural counties and urban counties with fewer than 20,000 people.