Mixed-Methods Study to Predict Upstaging of DCIS to Invasive Disease on Mammography.

BACKGROUND. The incidence of ductal carcinoma in situ (DCIS) has steadily increased, as have concerns regarding overtreatment. Active surveillance is a novel treatment strategy that avoids surgical excision, but identifying patients with occult invasive disease who should be excluded from active surveillance is challenging. Radiologists are not typically expected to predict the upstaging of DCIS to invasive disease, though they might be trained to perform this task. OBJECTIVE. The purpose of this study was to determine whether a mixed-methods two-stage observer study can improve radiologists' ability to predict upstaging of DCIS to invasive disease on mammography. METHODS. All cases of DCIS calcifications that underwent stereotactic biopsy between 2010 and 2015 were identified. Two cohorts were randomly generated, each containing 150 cases (120 pure DCIS cases and 30 DCIS cases upstaged to invasive disease at surgery). Nine breast radiologists reviewed the mammograms in the first cohort in a blinded fashion and scored the probability of upstaging to invasive disease. The radiologists then reviewed the cases and results collectively in a focus group to develop consensus criteria that could improve their ability to predict upstaging. The radiologists reviewed the mammograms from the second cohort in a blinded fashion and again scored the probability of upstaging. Statistical analysis compared the performances between rounds 1 and 2. RESULTS. The mean AUC for reader performance in predicting upstaging in round 1 was 0.623 (range, 0.514-0.684). In the focus group, radiologists agreed that upstaging was better predicted when an associated mass, asymmetry, or architectural distortion was present; when densely packed calcifications extended over a larger area; and when the most suspicious features were focused on rather than the most common features. Additionally, radiologists agreed that BI-RADS descriptors do not adequately characterize risk of invasion, and that microinvasive disease and smaller areas of DCIS will have poor prediction estimates. Reader performance significantly improved in round 2 (mean AUC, 0.765; range, 0.617-0.852; p = .045). CONCLUSION. A mixed-methods two-stage observer study identified factors that helped radiologists significantly improve their ability to predict upstaging of DCIS to invasive disease. CLINICAL IMPACT. Breast radiologists can be trained to better predict upstaging of DCIS to invasive disease, which may facilitate discussions with patients and referring providers.

Preliminary efficacy of a lovingkindness meditation intervention for patients undergoing biopsy and breast cancer surgery: A randomized controlled pilot study.

PURPOSE: Despite more women undergoing treatment for breast cancer and increased survival rates, many women suffer from anxiety and physical symptoms (e.g., pain, fatigue) surrounding diagnosis and surgery. Research investigating the efficacy of psychosocial interventions for breast cancer patients during this period is limited. This randomized controlled pilot study examined the effect of a brief lovingkindness meditation intervention on these key outcomes. METHODS: Participants were 60 women who underwent core needle breast biopsy, received an abnormal biopsy result, and underwent breast surgery (White = 73.6%; African American = 22.6%; Asian American = 3.8%; Age M = 56). Participants were randomly assigned to one of three treatment conditions at breast biopsy: (1) lovingkindness meditation, (2) music, and (3) usual care. Assessments of anxiety, pain, fatigue, physiologic reactivity, and self-compassion occurred prior to patients' biopsy, following biopsy, 1 week after receipt of biopsy results, and 1 week following breast surgery. RESULTS: Multilevel modeling analyses demonstrated that lovingkindness meditation significantly improved pain (p = 0.02), self-compassion (p = 0.004), and heart rate (p = 0.02) over time compared to control conditions. There was a trend for anxiety (p = 0.05). Music significantly improved pain (p = 0.04) compared to usual care. CONCLUSIONS: These findings provide preliminary evidence for the feasibility and efficacy of a lovingkindness meditation intervention for breast cancer patients during the diagnostic and surgical period. Improving psychological and physical well-being during this time frame has the potential to improve longer-term health outcomes during adjuvant treatment and survivorship. Interventions that cultivate positive adjustment during the diagnostic and surgical period of breast cancer are an important area of future research.

The relationship between holding back from communicating about breast concerns and anxiety in the year following breast biopsy.

PURPOSE: Evidence suggests open communication about breast cancer concerns promotes psychological adjustment, while holding back can lead to negative outcomes. Little is known about the relationship between communication and distress following breast biopsy. Design/ Sample: Women (N = 128) were assessed at the time of breast biopsy and again one week and three, six, and 12 months post-result. METHODS: Linear mixed modeling examined relationships between holding back and anxiety for women with benign results (n = 94) or DCIS/invasive disease (n = 34) following breast biopsy. FINDINGS: Anxiety increased among women with a benign result engaging in high but not low or average levels of holding back. Holding back was positively associated with anxiety post-result in breast cancer survivors, with anxiety decreasing over time. Conclusions/ Implications: Interventions to enhance communication are warranted, and knowledge of the differences among women with benign results and/or DCIS/invasive disease may allow for the development of tailored interventions.

Suspicious breast calcifications undergoing stereotactic biopsy in women ages 70 and over: Breast cancer incidence by BI-RADS descriptors.

OBJECTIVES: To determine the malignancy rate overall and for specific BI-RADS descriptors in women ≥70 years who undergo stereotactic biopsy for calcifications. METHODS: We retrospectively reviewed 14,577 consecutive mammogram reports in 6839 women ≥70 years to collect 231 stereotactic biopsies of calcifications in 215 women. Cases with missing images or histopathology and calcifications associated with masses, distortion, or asymmetries were excluded. Three breast radiologists determined BI-RADS descriptors by majority. Histology, hormone receptor status, and lymph node status were correlated with BI-RADS descriptors. RESULTS: There were 131 (57 %) benign, 22 (10 %) atypia/lobular carcinomas in situ, 55 (24 %) ductal carcinomas in situ (DCIS), and 23 (10 %) invasive diagnoses. Twenty-seven (51 %) DCIS cases were high-grade. Five (22 %) invasive cases were high-grade, two (9 %) were triple-negative, and three (12 %) were node-positive. Malignancy was found in 49 % (50/103) of fine pleomorphic, 50 % (14/28) of fine linear, 25 % (10/40) of amorphous, 20 % (3/15) of round, 3 % (1/36) of coarse heterogeneous, and 0 % (0/9) of dystrophic calcifications. CONCLUSIONS: Among women ≥70 years that underwent stereotactic biopsy for calcifications only, we observed a high rate of malignancy. Additionally, coarse heterogeneous calcifications may warrant a probable benign designation. KEY POINTS: • Cancer rates of biopsied calcifications in women ≥70 years are high • Radiologists should not dismiss suspicious calcifications in older women • Coarse heterogeneous calcifications may warrant a probable benign designation.

Positive and negative mood following imaging-guided core needle breast biopsy and receipt of biopsy results.

Positive and negative mood are independent psychological responses to stressful events. Negative mood negatively impacts well-being and co-occurring positive mood leads to improved adjustment. Women undergoing core needle breast biopsies (CNB) experience distress during CNB and awaiting results; however, influences of mood are not well known. This longitudinal study examines psychosocial and biopsy- and spirituality-related factors associated with mood in patients day of CNB and one week after receiving results. Ninety women undergoing CNB completed questionnaires on psychosocial factors (chronic stress, social support), biopsy experiences (pain, radiologist communication), and spirituality (peace, meaning, faith) day of CNB. Measures of positive and negative mood were completed day of CNB and one week after receiving results (benign n = 50; abnormal n = 25). Multiple linear regression analyses were conducted. Greater positive mood correlated with greater peace (ß = .25, p = .02) day of CNB. Lower negative mood correlated with greater peace (ß = -.29, p = .004) and there was a trend for a relationship with less pain during CNB (ß = .19, p = .07). For patients with benign results, day of CNB positive mood predicted positive mood post-results (ß = .31, p = .03) and only chronic stress predicted negative mood (ß = .33, p = .03). For women with abnormal results, greater meaning day of CNB predicted lower negative mood post-results (ß = -.45, p = .03). Meaning and peace may be important for women undergoing CNB and receiving abnormal results.

Now or Later? Patient Satisfaction and Anxiety Among Women Undergoing Breast Biopsies Performed the Same Day as Recommended Versus a Later Day.

PURPOSE: The aim of this study was to determine differences in patient satisfaction and anxiety among women undergoing core-needle breast biopsies performed the same day as recommended versus a future date. METHODS: After institutional review board exemption was granted, a survey was administered to patients at four sites on the day of imaging-guided core-needle breast biopsy. The survey was available from November 2020 through January 2022. Questions pertained to biopsy timing (same day versus later day), pre- and postbiopsy satisfaction with overall breast-care experience, biopsy wait-time satisfaction, pre- and postbiopsy anxiety, radiologist-patient communication, demographics, life stressors, breast cancer history, and risk factors. Comparisons were made between same-day and later-day biopsies by multivariable analysis. RESULTS: Of 974 respondents (response rate 65.6%), almost half were scheduled for same-day biopsies (47.8% [466 of 974]). In multivariate analyses, same-day biopsies were associated with higher prebiopsy overall breast-care satisfaction (P < .001), higher wait-time satisfaction (P < .001), and higher prebiopsy (P = .001) and postbiopsy anxiety (P = .001). Better radiologist-patient communication was associated with lower prebiopsy anxiety (P < .001) and greater prebiopsy overall (P < .001) and wait-time (P < .001) satisfaction. Compared with White women, Black women reported lower postbiopsy anxiety (P < .001) but also lower prebiopsy satisfaction (P = .03) and wait-time satisfaction (P < .001). CONCLUSIONS: Same-day versus later-day biopsies resulted in better prebiopsy overall breast-care and wait-time patient satisfaction scores; however, no satisfaction differences were noted after biopsy. Clinically significant anxiety was associated with both same- and later-day biopsies but was higher for same-day biopsies. Higher anxiety levels correlated with lower overall satisfaction, suggesting that interventions to reduce anxiety and improve communication could improve patient experiences during same-day biopsies.

Using the BI-RADS lexicon in a restrictive form of double reading as a strategy for minimizing screening mammography recall rates.

OBJECTIVE: The purpose of this article is to determine the potential reduction in screening recall rates by strictly following standardized BI-RADS lexicon for lesions seen on screening mammography. MATERIALS AND METHODS: Of 3084 consecutive mammograms performed at our screening facilities, 345 women with 437 lesions were recalled for additional imaging and constituted our study population. Three radiologists retrospectively classified lesions using the standard BI-RADS lexicon and assigned each to one of four groups: group A, the finding met criteria for recall by the BI-RADS lexicon; group B, the finding did not meet strict BI-RADS criteria for recall but was sufficiently indeterminate to warrant recall by the majority of the study panel; group C, the finding was classifiable by the BI-RADS lexicon but was not recalled because it was benign or stable; and group D, the questioned finding was not considered an abnormality by our study panel. Recall rates and the cancer detection rate were determined. The adjusted recall rate was calculated for lesions considered appropriate for recall (group A), and the reduction in the recall rate was determined. RESULTS: Nineteen malignancies were detected in our recalled population, for a cancer detection rate of 0.65%. All 19 malignancies were lesions considered appropriate for recall (group A). If only group A lesions had been recalled, the recall rate would have decreased from 11.4% to 6.2%, representing a 46% reduction in recalls without affecting the cancer detection rate. CONCLUSION: Using the BI-RADS lexicon as a decision-making aid may help adjust thresholds for recalling indeterminate or suspicious lesions and reduce recall rates from screening mammography.

Managing Challenging Patient Interactions in Breast Imaging.

Managing challenging patient interactions can be a daily stressor for breast imaging radiologists, leading to burnout. This article offers communication and behavioral practices for radiologists that help reduce radiologists' stress during these encounters. Patient scenarios viewed as difficult can vary among radiologists. Radiologists' awareness of their own physical, mental, and emotional states, along with skillful communications, can be cultivated to navigate these interactions and enhance resiliency. Understanding underlying causes of patients' emotional reactions, denial, and anger helps foster empathy and compassion during discussions. When exposed to extremely disruptive, angry, or racially abusive patients, having pre-existing institutional policies to address these behaviors helps direct appropriate responses and guide subsequent actions. These extreme behaviors may catch breast imaging radiologists off guard yet have potentially significant consequences. Rehearsing scripted responses before encounters can help breast imaging radiologists maintain composure in the moment, responding in a calm, nonjudgmental manner, and most effectively contributing to service recovery. However, when challenging patient encounters do trigger difficult emotions in breast imaging radiologists, debriefing with colleagues afterwards and naming the emotion can help the radiologists process their feelings to regain focus for performing clinical duties.

Comparative performance of multiview stereoscopic and mammographic display modalities for breast lesion detection.

PURPOSE: Mammography is known to be one of the most difficult radiographic exams to interpret. Mammography has important limitations, including the superposition of normal tissue that can obscure a mass, chance alignment of normal tissue to mimic a true lesion and the inability to derive volumetric information. It has been shown that stereomammography can overcome these deficiencies by showing that layers of normal tissue lay at different depths. If standard stereomammography (i.e., a single stereoscopic pair consisting of two projection images) can significantly improve lesion detection, how will multiview stereoscopy (MVS), where many projection images are used, compare to mammography? The aim of this study was to assess the relative performance of MVS compared to mammography for breast mass detection. METHODS: The MVS image sets consisted of the 25 raw projection images acquired over an arc of approximately 45 degrees using a Siemens prototype breast tomosynthesis system. The mammograms were acquired using a commercial Siemens FFDM system. The raw data were taken from both of these systems for 27 cases and realistic simulated mass lesions were added to duplicates of the 27 images at the same local contrast. The images with lesions (27 mammography and 27 MVS) and the images without lesions (27 mammography and 27 MVS) were then postprocessed to provide comparable and representative image appearance across the two modalities. All 108 image sets were shown to five full-time breast imaging radiologists in random order on a state-of-the-art stereoscopic display. The observers were asked to give a confidence rating for each image (0 for lesion definitely not present, 100 for lesion definitely present). The ratings were then compiled and processed using ROC and variance analysis. RESULTS: The mean AUC for the five observers was 0.614 +/- 0.055 for mammography and 0.778 +/- 0.052 for multiview stereoscopy. The difference of 0.164 +/- 0.065 was statistically significant with a p-value of 0.0148. CONCLUSIONS: The differences in the AUCs and the p-value suggest that multiview stereoscopy has a statistically significant advantage over mammography in the detection of simulated breast masses. This highlights the dominance of anatomical noise compared to quantum noise for breast mass detection. It also shows that significant lesion detection can be achieved with MVS without any of the artifacts associated with tomosynthesis.

Molecular Subtypes of Breast Cancer: A Review for Breast Radiologists.

Gene expression profiling has reshaped our understanding of breast cancer by identifying four molecular subtypes: (1) luminal A, (2) luminal B, (3) human epidermal growth factor receptor 2 (HER2)-enriched, and (4) basal-like, which have critical differences in incidence, response to treatment, disease progression, survival, and imaging features. Luminal tumors are most common (60%-70%), characterized by estrogen receptor (ER) expression. Luminal A tumors have the best prognosis of all subtypes, whereas patients with luminal B tumors have significantly shorter overall and disease-free survival. Distinguishing between these tumors is important because luminal B tumors require more aggressive treatment. Both commonly present as irregular masses without associated calcifications at mammography; however, luminal B tumors more commonly demonstrate axillary involvement at diagnosis. HER2-enriched tumors are characterized by overexpression of the HER2 oncogene and low-to-absent ER expression. HER2+ disease carries a poor prognosis, but the development of anti-HER2 therapies has greatly improved outcomes for women with HER2+ breast cancer. HER2+ tumors most commonly present as spiculated masses with pleomorphic calcifications or as calcifications alone. Basal-like cancers (15% of all invasive breast cancers) predominate among "triple negative" cancers, which lack ER, progesterone receptor (PR), and HER2 expression. Basal-like cancers are frequently high-grade, large at diagnosis, with high rates of recurrence. Although imaging commonly reveals irregular masses with ill-defined or spiculated margins, some circumscribed basal-like tumors can be mistaken for benign lesions. Incorporating biomarker data (histologic grade, ER/PR/HER2 status, and multigene assays) into classic anatomic tumor, node, metastasis (TNM) staging can better inform clinical management of this heterogeneous disease.

Dreams prior to biopsy for suspected breast cancer: A preliminary survey.

Warning dreams prior to the onset of symptoms have been reported in a previous survey of self-selected women with breast cancer. There is no available data on how many women with suspected breast cancer have such dreams, so anonymous surveys were offered to women who came for biopsy at a university breast imaging center over a period of 3 months. 163 women completed the survey reporting that 64% usually remember their dreams, 41% have had dreams that came true, and 5% keep a dream diary. 5.5% reported dreaming the word "cancer," but only one woman was prompted to have a breast evaluation because of a dream. This pilot data will be used in planning a future study with pathological correlation.

Ductal Carcinoma In Situ Biology, Language, and Active Surveillance: A Survey of Breast Radiologists' Knowledge and Opinions.

PURPOSE: To understand how breast radiologists perceive ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: A 19-item survey was developed by the Society of Breast Imaging Patient Care and Delivery Committee and distributed to all Society of Breast Imaging members. The survey queried respondents' demographics, knowledge of DCIS biology, language used to discuss a new diagnosis of DCIS, and perspectives on active surveillance for DCIS. Five-point Likert scales (1 = strongly disagree, 3 = neutral, 5 = strongly agree) were used. RESULTS: There were 536 responses for a response rate of 41%. There was agreement that DCIS is the primary driver of overdiagnosis in breast cancer screening (median 4), and respondents provided mean and median overdiagnosis estimates of 29.7% and 25% for low-grade DCIS as well as 4.2% and 0% for high-grade DCIS, respectively. Responses varied in how to describe DCIS but most often used the word "cancer" with a qualifier such as "early" (32%) or "pre-invasive" (25%). Respondents disagreed (median 2) with removing the word "carcinoma" from DCIS. Finally, there was agreement that current standard of care therapy for some forms of DCIS is overtreatment (median 4) and that active surveillance as an alternative management strategy should be studied (mean 4), but felt that ultrasound (median 4) and MRI (median 4) should be used to exclude women with occult invasive disease before active surveillance. CONCLUSIONS: Breast radiologists' opinions about DCIS biology, language, and active surveillance are not homogenous, but general trends exist that can be used to guide research, education, and advocacy efforts.

Unmet Spiritual Care Needs in Women Undergoing Core Needle Breast Biopsy.

OBJECTIVE: Spiritual care is an important part of healthcare, especially when patients face a possible diagnosis of a life-threatening disease. This study examined the extent to which women undergoing core-needle breast biopsy desired spiritual support and the degree to which women received the support they desired. METHODS: Participants (N = 79) were women age 21 and older, who completed an ultrasound- or stereotactic-guided core-needle breast biopsy. Participants completed measures of spiritual needs and spiritual care. Medical and sociodemographic information were also collected. Independent sample t-tests and chi-square tests of examined differences based on demographic, medical, and biopsy-related variables. RESULTS: Forty-eight participants (48/79; 60.8%) desired some degree of spiritual care during their breast biopsy, and 33 participants (33/78; 42.3%) wanted their healthcare team to address their spiritual needs. African American women were significantly more likely to desire some type of spiritual support compared to women who were not African American. Among the 79 participants, 16 (20.3%) reported a discrepancy between desired and received spiritual support. A significant association between discrepancies and biopsy results was found, χ 2(1) = 4.19, P = .04, such that 2 (7.4%) of 27 participants with results requiring surgery reported discrepancies, while 14 (26.9%) of 52 participants with a benign result reported discrepancies. CONCLUSION: Most women undergoing core-needle breast biopsy desired some degree of spiritual care. Although most reported that their spiritual needs were addressed, a subset of women received less care than desired. Our results suggest that healthcare providers should be aware of patients' desires for spiritual support, particularly among those with benign results.

Predicting Upstaging of DCIS to Invasive Disease: Radiologists's Predictive Performance.

RATIONALE AND OBJECTIVES: The purpose of this study is to quantify breast radiologists' performance at predicting occult invasive disease when ductal carcinoma in situ (DCIS) presents as calcifications on mammography and to identify imaging and histopathological features that are associated with radiologists' performance. MATERIALS AND METHODS: Mammographically detected calcifications that were initially diagnosed as DCIS on core biopsy and underwent definitive surgical excision between 2010 and 2015 were identified. Thirty cases of suspicious calcifications upstaged to invasive ductal carcinoma and 120 cases of DCIS confirmed at the time of definitive surgery were randomly selected. Nuclear grade, estrogen and progesterone receptor status, patient age, calcification long axis length, and breast density were collected. Ten breast radiologists who were blinded to all clinical and pathology data independently reviewed all cases and estimated the likelihood that the DCIS would be upstaged to invasive disease at surgical excision. Subgroup analysis was performed based on nuclear grade, long axis length, breast density and after exclusion of microinvasive disease. RESULTS: Reader performance to predict upstaging ranged from an area under the receiver operating characteristic curve (AUC) of 0.541-0.684 with a mean AUC of 0.620 (95%CI: 0.489-0.751). Performances improved for lesions smaller than 2 cm (AUC: 0.676 vs 0.500; p = 0.002). The exclusion of microinvasive cases also improved performance (AUC: 0.651 vs 0.620; p = 0.005). There was no difference in performance based on breast density (p = 0.850) or nuclear grade (p = 0.270) CONCLUSION: Radiologists were able to predict invasive disease better than chance, particularly for smaller DCIS lesions (<2 cm) and after the exclusion of microinvasive disease.

Optimizing the Patient Experience during Breast Biopsy.

For years, breast imaging has been the model in radiology for patient communication, and more recently, it has been a leader in the growing patient- and family-centered approach to care. To maintain high levels of patient satisfaction during image-guided core-needle breast biopsies, the radiologist should understand patient perspectives so that interventions can be developed to manage patient concerns. This article reviews patient perspectives before, during, and after imaging-guided breast biopsies, and it describes strategies to help optimize the experiences of patients as they navigate the process.

Screening Guidelines and Supplemental Screening Tools: Assessment of the Adequacy of Patient-Provider Discussions.

PURPOSE: To assess breast imaging radiologists' perceptions of the adequacy of provider-patient discussions regarding the benefits and risks of screening mammography and supplemental screening in women with elevated risk and dense breasts. METHODS: A 36-item questionnaire developed by the Society of Breast Imaging Patient Care and Delivery Task Force was distributed electronically to Society of Breast Imaging members to evaluate patient communication, education, and screening practices. Data from the 11 items specifically pertaining to screening practices were analyzed. RESULTS: The response rate was 14% (275/1992). Seventy-four percent of survey respondents perceived provider-patient discussions regarding mammography screening guidelines as inadequate, and they agreed that provider-patient discussions regarding screening guidelines (82%) and supplemental screening for increased breast density (74%) should be standardized. Only 38% indicated that mammography screening guidelines are officially endorsed by their institution. Similarly, 37% reported that recommendations were up to the primary provider. Although most respondents include information about breast density in lay letters (73%) and radiology reports (89%), many feel that further patient education regarding breast density, supplemental screening, risk assessment, and screening guidelines should be performed by radiologists, and they are willing to provide additional patient education in these areas in practice. CONCLUSIONS: Survey respondents perceived current provider-patient discussions about the risks and benefits of breast cancer mammography screening and supplemental screening as inadequate and felt that standards should be developed. Respondents reported a willingness to take on patient education as part of their daily practice. These findings could inform future initiatives for radiologists to contribute to enhancing provider-patient education.

Exploiting heat shock protein expression to develop a non-invasive diagnostic tool for breast cancer.

Leveraging the unique surface expression of heat shock protein 90 (Hsp90) in breast cancer provides an exciting opportunity to develop rapid diagnostic tests at the point-of-care setting. Hsp90 has previously been shown to have elevated expression levels across all breast cancer receptor subtypes. We have developed a non-destructive strategy using HS-27, a fluorescently-tethered Hsp90 inhibitor, to assay surface Hsp90 expression on intact tissue specimens and validated our approach in clinical samples from breast cancer patients across estrogen receptor positive, Her2-overexpressing, and triple negative receptor subtypes. Utilizing a pre-clinical biopsy model, we optimized three imaging parameters that may affect the specificity of HS-27 based diagnostics - time between tissue excision and staining, agent incubation time, and agent dose, and translated our strategy to clinical breast cancer samples. Findings indicated that HS-27 florescence was highest in tumor tissue, followed by benign tissue, and finally followed by mammoplasty negative control samples. Interestingly, fluorescence in tumor samples was highest in Her2+ and triple negative subtypes, and inversely correlated with the presence of tumor infiltrating lymphocytes indicating that HS-27 fluorescence increases in aggressive breast cancer phenotypes. Development of a Gaussian support vector machine classifier based on HS-27 fluorescence features resulted in a sensitivity and specificity of 82% and 100% respectively when classifying tumor and benign conditions, setting the stage for rapid and automated tissue diagnosis at the point-of-care.

Relationship between Background Parenchymal Enhancement on High-risk Screening MRI and Future Breast Cancer Risk.

RATIONALE AND OBJECTIVES: To determine if background parenchymal enhancement (BPE) on screening breast magnetic resonance imaging (MRI) in high-risk women correlates with future cancer. MATERIALS AND METHODS: All screening breast MRIs (n = 1039) in high-risk women at our institution from August 1, 2004, to July 30, 2013, were identified. Sixty-one patients who subsequently developed breast cancer were matched 1:2 by age and high-risk indication with patients who did not develop breast cancer (n = 122). Five fellowship-trained breast radiologists independently recorded the BPE. The median reader BPE for each case was calculated and compared between the cancer and control cohorts. RESULTS: Cancer cohort patients were high-risk because of a history of radiation therapy (10%, 6 of 61), high-risk lesion (18%, 11 of 61), or breast cancer (30%, 18 of 61); BRCA mutation (18%, 11 of 61); or family history (25%, 15 of 61). Subsequent malignancies were invasive ductal carcinoma (64%, 39 of 61), ductal carcinoma in situ (30%, 18 of 61) and invasive lobular carcinoma (7%, 4of 61). BPE was significantly higher in the cancer cohort than in the control cohort (P = 0.01). Women with mild, moderate, or marked BPE were 2.5 times more likely to develop breast cancer than women with minimal BPE (odds ratio = 2.5, 95% confidence interval: 1.3-4.8, P = .005). There was fair interreader agreement (κ = 0.39). CONCLUSIONS: High-risk women with greater than minimal BPE at screening MRI have increased risk of future breast cancer.

Frequency of Breast Cancer Thoughts and Lifetime Risk Estimates: A Multi-Institutional Survey of Women Undergoing Screening Mammography.

PURPOSE: The aim of this study was to quantify women's personal estimates of breast cancer risk and frequency of breast cancer thoughts. METHODS: Women from five medical centers were surveyed before their screening mammographic examinations. Participants were queried on their baseline anxiety and demographics, then asked how many times in the past month they had thought about developing breast cancer. Participants were then notified of the 12% lifetime average breast cancer risk and asked to estimate their personal risk both subjectively and objectively. Comparisons were made between responses and the demographic variables. RESULTS: There were 2,747 completed surveys for analysis. Women reported 2.5 ± 6.6 thoughts of cancer on average in the prior month. More frequent thoughts were associated with personal or family history of breast cancer, greater anxiety, and genetic testing (P < .001 for all). Among women without cancer risk factors (n = 1,412), there were 1.4 cancer thoughts per month, which was associated with baseline anxiety (P < .001). The median lifetime breast cancer risk was 12% among all women, with 37.4% high risk (>20%) estimates. Demographic variables associated with increased risk estimates were previous cancer diagnosis, higher education, genetic testing, white race, increased age, and greater anxiety (P < .01 for all). Among women with no risk factors, the median estimated risk was 10%, with 16.7% providing estimates greater than 20%, associated with baseline anxiety and white race (P < .001 for both). CONCLUSIONS: Increased breast cancer thoughts and personal cancer estimates are associated with specific patient demographics. Improved understanding of patient perspectives could improve shared decision-making discussions and thus patient care.

Radiologist-Patient Communication: Current Practices and Barriers to Communication in Breast Imaging.

PURPOSE: The aim of this study was to assess variability in radiologist-patient communication practices and barriers to communication among members of the Society of Breast Imaging (SBI). METHODS: A 36-item questionnaire developed by the SBI Patient Care and Delivery Task Force was distributed electronically to SBI members to evaluate patient communication, education, and screening practices. Data from 14 items investigating patient communication (eg, practices, comfort, barriers to communication) were analyzed and compared with demographic variables using χ2 or independent t tests as appropriate. RESULTS: Ninety-three percent of radiologists reported that they directly communicate abnormal results of diagnostic mammographic examinations that require biopsy and malignant or high-risk biopsy results that require surgery. Radiologists (66%) and technologists (57%) often provide normal or negative diagnostic mammographic results. Most respondents were completely comfortable discussing the need for additional imaging, recommending biopsy, and discussing biopsy results directly with patients, and 71% rated their communication skills as excellent. Radiologists who spend less time in breast imaging reported only average communication skills. The most frequent barriers to communication were that practices were not set up for direct communication (loss of revenue) and discomfort with angry patients. CONCLUSIONS: Although variation in breast imaging communication practices exists among radiologists and practice types, the majority of radiologists directly communicate the most distressing results to patients, such as those regarding abnormal diagnostic mammographic findings requiring biopsies and abnormal biopsy results leading to cancer diagnoses and surgery. The majority of radiologists are completely comfortable with these conversations, but all feel that enhancing communication with patients will lead to greater patient satisfaction.