Think of ink: Tattoo pigment masquerading as a breast mass.

Migration of tattoo pigment to axillary lymph nodes mimicking calcifications is a recognized phenomenon, however, pigment in an intra-mammary node masquerading as a breast mass is a rare complication of cosmetic tattoos. As the prevalence of tattooing increases among women presenting to Breastscreen, radiologists may expect to encounter this lesion mimicking a breast neoplasm. We present a 50-year-old female with extensive tattoos on her arms, chest wall and abdomen, recalled for a small calcified breast mass on her first screening mammogram. Tomosynthesis-guided vacuum-assisted biopsy demonstrated intra-mammary lymph node with abundant tattoo pigment.

The impact of height and weight on rescreening rates within a population-based breast screening program.

INTRODUCTION: Women with obesity are at increased risk of post-menopausal breast cancer and less likely to participate in breast screening. This study investigates the impact of asking women their height and weight within a population-based screening program, and the association of BMI with rescreening status. METHODS: Data regarding 666,130 screening events from 318,198 women aged 50-74 attending BreastScreen Western Australia between 2016 and 2021 were used to compare crude and age-standardised rescreening rates over time. Mixed effects logistic regression was used to investigate associations of BMI with rescreening status. RESULTS: Rescreening rates for women screened since 2016 were within 1.8% points from the previous reporting period, stratified by screening round. Increasing BMI was associated with decreased likelihood of returning to breast screening (OR = 0.993, 95% CI: 0.988-0.998; OR = 0.989, 95% CI: 0.984-0.994; OR = 0.985, 95% CI: 0.982-0.987 for women screening for the first, second and third+ time, respectively). CONCLUSIONS: This large, prospective study supports implementation of routine height and weight collection within breast screening programs. It shows that asking women their height and weight does not deter them from returning to screening and that women with increased BMI are less likely to rescreen, highlighting a need for targeted interventions to improve screening barriers for women living with obesity.

Health benefits and harms of mammography screening in older women (75+ years)-a systematic review.

BACKGROUND: There is little evidence on the balance between potential benefits and harms of mammography screening in women 75 years and older. The aim of this systematic review was to synthesise the evidence on the outcomes of mammography screening in women aged 75 years and older. METHODS: A systematic review of mammography screening studies in women aged 75 years and over. RESULTS: Thirty-six studies were included in this review: 27 observational studies and 9 modelling studies. Many of the included studies used no or uninformative comparison groups resulting in a potential bias towards the benefits of screening. Despite this, there was mixed evidence about the benefits and harms of continuing mammography screening beyond the age of 75 years. Some studies showed a beneficial effect on breast cancer mortality, and other studies showed no effect on mortality. Some studies showed some harms (false positive tests and recalls) being comparable to those in younger age-groups, with other studies showing increase in false positive screens and biopsies in older age-group. Although reported in fewer studies, there was consistent evidence of increased overdiagnosis in older age-groups. CONCLUSION: There is limited evidence available to make a recommendation for/against continuing breast screening beyond the age of 75 years. Future studies should use more informative comparisons and should estimate overdiagnosis given potentially substantial harm in this age-group due to competing causes of death. This review was prospectively registered with PROSPERO (CRD42020203131).

Radial scar appearances on contrast-enhanced mammography.

With modern technological advances in imaging, radial scars are more frequently encountered in clinical practice. The management of radial scars remains challenging due to associated upgrade to malignancy at excision. Contrast-enhanced mammography (CEM) has a similar sensitivity compared to MRI in addition to lower cost, better availability and fewer contra-indications. CEM is reported to have an overall excellent negative predictive value for malignancy. In this study, imaging of 55 patients with a core biopsy diagnosis of radial scar since the introduction of CEM into local practice was reviewed. Nine patients underwent CEM as part of their diagnostic work-up and these appearances are presented as a pictorial essay to demonstrate enhancement patterns of radial scars on CEM in this cohort and consider how this knowledge may influence management.

The association between breast arterial calcification and atherosclerotic cardiovascular disease in an Australian population-based breast cancer case-control study.

PURPOSE: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity and mortality. Breast arterial calcification (BAC) on mammograms is not associated with breast cancer risk. However, there is increasing evidence supporting its association with cardiovascular disease (CVD). This study examines the association between BAC and ASCVD and their risk factors within an Australian population-based breast cancer study. MATERIALS AND METHODS: Data from the controls who participated in the breast cancer environment and employment study (BCEES) were linked with the Western Australian Department of Health Hospital Morbidity database and Mortality Registry to obtain ASCVD outcomes and related risk factor data. Mammograms from participants with no prior history of ASCVD were assessed for BAC by a radiologist. Cox proportional hazards regression was used to examine the association between BAC and later occurrence of an ASCVD event. Logistic regression was used to investigate the factors associated with BAC. RESULTS: A total of 1020 women with a mean age of 60 (sd = 7.0 years) were included and BAC found in 184 (18.0%). Eighty (7.8%) of the 1020 participants developed ASCVD, with an average time to event of 6.2 years (sd = 4.6) from baseline. In univariate analysis, participants with BAC were more likely to have an ASCVD event (HR = 1.96 95% CI 1.29-2.99). However, after adjusting for other risk factors, this association attenuated (HR = 1.37 95% CI 0.88-2.14). Increasing age (OR = 1.15, 95% CI 1.12-1.19) and parity (pLRT < 0.001) were associated with BAC. CONCLUSION: BAC is associated with increased ASCVD risk, but this is not independent of cardiovascular risk factors.

Artificial intelligence (AI) for breast cancer screening: BreastScreen population-based cohort study of cancer detection.

BACKGROUND: Artificial intelligence (AI) has been proposed to reduce false-positive screens, increase cancer detection rates (CDRs), and address resourcing challenges faced by breast screening programs. We compared the accuracy of AI versus radiologists in real-world population breast cancer screening, and estimated potential impacts on CDR, recall and workload for simulated AI-radiologist reading. METHODS: External validation of a commercially-available AI algorithm in a retrospective cohort of 108,970 consecutive mammograms from a population-based screening program, with ascertained outcomes (including interval cancers by registry linkage). Area under the ROC curve (AUC), sensitivity and specificity for AI were compared with radiologists who interpreted the screens in practice. CDR and recall were estimated for simulated AI-radiologist reading (with arbitration) and compared with program metrics. FINDINGS: The AUC for AI was 0.83 compared with 0.93 for radiologists. At a prospective threshold, sensitivity for AI (0.67; 95% CI: 0.64-0.70) was comparable to radiologists (0.68; 95% CI: 0.66-0.71) with lower specificity (0.81 [95% CI: 0.81-0.81] versus 0.97 [95% CI: 0.97-0.97]). Recall rate for AI-radiologist reading (3.14%) was significantly lower than for the BSWA program (3.38%) (-0.25%; 95% CI: -0.31 to -0.18; P < 0.001). CDR was also lower (6.37 versus 6.97 per 1000) (-0.61; 95% CI: -0.77 to -0.44; P < 0.001); however, AI detected interval cancers that were not found by radiologists (0.72 per 1000; 95% CI: 0.57-0.90). AI-radiologist reading increased arbitration but decreased overall screen-reading volume by 41.4% (95% CI: 41.2-41.6). INTERPRETATION: Replacement of one radiologist by AI (with arbitration) resulted in lower recall and overall screen-reading volume. There was a small reduction in CDR for AI-radiologist reading. AI detected interval cases that were not identified by radiologists, suggesting potentially higher CDR if radiologists were unblinded to AI findings. These results indicate AI's potential role as a screen-reader of mammograms, but prospective trials are required to determine whether CDR could improve if AI detection was actioned in double-reading with arbitration. FUNDING: National Breast Cancer Foundation (NBCF), National Health and Medical Research Council (NHMRC).

Reflections from Women with an Interval Breast Cancer Diagnosis: A Qualitative Analysis of Open Disclosure in the BreastScreen Western Australia Program.

BACKGROUND: 'Interval breast cancer' describes a malignancy that is diagnosed after a negative screening mammogram. Open disclosure is a process of addressing a negative health outcome that includes an apology and an opportunity for the client to discuss concerns. BreastScreen Western Australia has implemented a policy of open disclosure. The purpose of this study was to gain an understanding of clients' experience with interval cancer and their attitude towards the screening programme by conducting a thematic analysis of written responses from women participating in the open disclosure process. METHODS: Women experiencing an interval cancer diagnosis between 2011 and 2020 were sent a questionnaire by mail. It included two broad questions with free-text responses. A qualitative analysis of the responses was conducted using an inductive approach. Responses were de-identified and data were thematically analysed and presented using verbatim quotations. RESULTS: Five themes emerged in response to "what could we have done better?": 'nothing,' 'broaden scope,' 'service delivery,' 'breast density education' and 'more education' generally. Six themes emerged in response to "what did we do well?": 'staffing,' 'overall satisfaction,' 'reminders,' 'follow-up after interval cancer,' 'efficiency' and 'information and education provision.' An additional theme of 'storytelling' emerged from both questions: an opportunity for the woman to share her experience of cancer. CONCLUSION: Most women expressed positive attitudes towards the service and appreciated giving feedback in the open disclosure process. Several themes supporting the role of BreastScreen in education were identified, including providing information about breast density, breast health, and limitations of screening.

Come Roll with Me: An Interprofessional Experience to Promote Disability Awareness.

Problem: One in four American adults have a disability, which makes people with disabilities the largest minority group in the United States (U.S.). Chronic diseases are prevalent within this population, which faces myriad barriers that limit access to healthcare and create significant health care disparities. Yet, disability awareness programs are limited in U.S. medical schools and graduates report a sense of unpreparedness to care for this population. Intervention: Come Roll with Me (CRWM) was implemented as an interprofessional, preclinical experience to provide medical and Doctor of Physical Therapy (DPT) students an opportunity to engage with wheelchair users and one another. Students rotated through four stations with a licensed physical therapist and wheelchair user facilitator. Stations included (1) manual wheelchair self-propulsion, (2) accessible parking, (3) transfers, and (4) open dialog on barriers to healthcare led by the wheelchair user. Context: This study sought to assess the impact of CRWM on students' understanding of the barriers and health disparities faced by individuals with disabilities. Assessment was conducted using course evaluations, thematic analysis of student reflection essays and a focus group with the wheelchair user facilitators to determine if CRWM met pre-implementation program goals and objectives, including the Interprofessional Educational Collaborative (IPEC) core competencies. Impact: Student reflections from both disciplines indicated that learners were able to identify a variety of barriers faced by people with disabilities and prioritize methods to mitigate these factors. Approximately 91% of medical students agreed or strongly agreed that CRWM was effective in their learning on course evaluations. Wheelchair user facilitators noted three important outcomes of CRWM: educating, teaming, and impact on students. Lesson Learned: Come Roll with Me is a robust educational activity, as evidenced by the program meeting all goals and objectives as well as (IPEC) core competencies. It provides students a unique opportunity to learn about disability from another profession and wheelchair users. People with disabilities and DPT students are a unique and underutilized pool of educators in undergraduate medical education.

Mammary schistosomiasis: A rare case.

Schistosomiasis is prevalent in some developing countries; however, it does not commonly affect the breast. Mammary schistosomiasis may present as suspicious microcalcification or a mass on mammography. Image-guided biopsy is necessary to exclude malignancy and identify calcified Schistosoma ova on histology. We report a case of a patient born in the Philippines who was diagnosed with mammary schistosomiasis from incidental microcalcifications seen on mammography.

Evidence from a BreastScreen cohort does not support a longer inter-screen interval in women who have no conventional risk factors for breast cancer.

OBJECTIVES: To determine screening outcomes in women who have no recorded risk factors for breast cancer. METHODS: A retrospective population-based cohort study included all 1,026,137 mammography screening episodes in 323,082 women attending the BreastScreen Western Australia (part of national biennial screening) program between July 2007 and June 2017. Cancer detection rates (CDR) and interval cancer rates (ICR) were calculated in screening episodes with no recorded risk factors for breast cancer versus at least one risk factor stratified by age. CDR was further stratified by timeliness of screening (<27 versus ≥27 months); ICR was stratified by breast density. RESULTS: Amongst 566,948 screens (55.3%) that had no recorded risk factors, 2347 (40.9%) screen-detected cancers were observed. In screens with no risk factors, CDR was 50 (95%CI 48-52) per 10,000 screens and ICR was 7.9 (95%CI 7.4-8.4) per 10,000 women-years, estimates that were lower than screens with at least one risk factor (CDR 83 (95%CI 80-86) per 10,000 screens, ICR 12.2 (95%CI 11.5-13.0) per 10,000 women-years). Compared to timely screens with risk factors, delayed screens with no risk factors had similar CDR across all age groups and a higher proportion of node positive cancers (26.1% vs 20.7%). ICR was lowest in screens that had no risk factors nor dense breasts in all age groups. CONCLUSIONS: Majority of screens had no recorded breast cancer risk factors, hence a substantial proportion of screen-detected cancers occur in these screening episodes. Our findings may not justify less frequent screening in women with no risk factors.

The impact of breast density notification on rescreening rates within a population-based mammographic screening program.

BACKGROUND: High participation in mammographic screening is essential for its effectiveness to detect breast cancers early and thereby, improve breast cancer outcomes. Breast density is a strong predictor of breast cancer risk and significantly reduces the sensitivity of mammography to detect the disease. There are increasing mandates for routine breast density notification within mammographic screening programs. It is unknown if breast density notification impacts the likelihood of women returning to screening when next due (i.e. rescreening rates). This study investigates the association between breast density notification and rescreening rates using individual-level data from BreastScreen Western Australia (WA), a population-based mammographic screening program. METHODS: We examined 981,705 screening events from 311,656 women aged 40+ who attended BreastScreen WA between 2008 and 2017. Mixed effect logistic regression was used to investigate the association between rescreening and breast density notification status. RESULTS: Results were stratified by age (younger, targeted, older) and screening round (first, second, third+). Targeted women screening for the first time were more likely to return to screening if notified as having dense breasts (Percentunadjusted notified vs. not-notified: 57.8% vs. 56.1%; Padjusted = 0.016). Younger women were less likely to rescreen if notified, regardless of screening round (all P < 0.001). There was no association between notification and rescreening in older women (all P > 0.72). CONCLUSIONS: Breast density notification does not deter women in the targeted age range from rescreening but could potentially deter younger women from rescreening. These results suggest that all breast density notification messaging should include information regarding the importance of regular mammographic screening to manage breast cancer risk, particularly for younger women. These results will directly inform BreastScreen programs in Australia as well as other population-based screening providers outside Australia who notify women about breast density or are considering implementing breast density notification.

Artificial intelligence (AI) to enhance breast cancer screening: protocol for population-based cohort study of cancer detection.

INTRODUCTION: Artificial intelligence (AI) algorithms for interpreting mammograms have the potential to improve the effectiveness of population breast cancer screening programmes if they can detect cancers, including interval cancers, without contributing substantially to overdiagnosis. Studies suggesting that AI has comparable or greater accuracy than radiologists commonly employ 'enriched' datasets in which cancer prevalence is higher than in population screening. Routine screening outcome metrics (cancer detection and recall rates) cannot be estimated from these datasets, and accuracy estimates may be subject to spectrum bias which limits generalisabilty to real-world screening. We aim to address these limitations by comparing the accuracy of AI and radiologists in a cohort of consecutive of women attending a real-world population breast cancer screening programme. METHODS AND ANALYSIS: A retrospective, consecutive cohort of digital mammography screens from 109 000 distinct women was assembled from BreastScreen WA (BSWA), Western Australia's biennial population screening programme, from November 2016 to December 2017. The cohort includes 761 screen-detected and 235 interval cancers. Descriptive characteristics and results of radiologist double-reading will be extracted from BSWA outcomes data collection. Mammograms will be reinterpreted by a commercial AI algorithm (DeepHealth). AI accuracy will be compared with that of radiologist single-reading based on the difference in the area under the receiver operating characteristic curve. Cancer detection and recall rates for combined AI-radiologist reading will be estimated by pairing the first radiologist read per screen with the AI algorithm, and compared with estimates for radiologist double-reading. ETHICS AND DISSEMINATION: This study has ethical approval from the Women and Newborn Health Service Ethics Committee (EC00350) and the Curtin University Human Research Ethics Committee (HRE2020-0316). Findings will be published in peer-reviewed journals and presented at national and international conferences. Results will also be disseminated to stakeholders in Australian breast cancer screening programmes and policy makers in population screening.

An atypically located pleomorphic adenoma: Radiological and pathological correlation.

Pleomorphic adenoma is a common benign salivary gland neoplasm which very rarely occurs in the breast. Its radiologic and pathologic appearance may be mistaken for other benign or malignant lesions such as a fibroadenoma or invasive ductal carcinoma. Due to the risk of local recurrence and, rarely, malignant transformation, wide local excision with clear margins is recommended. As such, a correct diagnosis of this lesion is important to ensure appropriate surgical treatment. We report a case of an atypically located pleomorphic adenoma with radiologic-pathologic correlation in an asymptomatic 63-year-old woman.

Radiological and pathological correlation of a rare case of primary breast follicular lymphoma in a male patient, presenting as gynaecomastia.

We present an exceptionally rare case of primary breast follicular lymphoma in a male patient, who presented to us with gynaecomastia for investigation. To our knowledge there have only been two other cases published in the literature to date. In Western Australia, there have been no cases in at least the past 10 years. This particular case highlights the importance of radiological and pathological correlation in making the diagnosis, particularly in the assessment of breast lumps in a male patient, where imaging and clinical findings alone could not make the diagnosis.

Bloody nipple discharge in Carney complex: A case report.

Carney complex (CNC) is an extremely rare, autosomal dominant genetic syndrome consisting of pigmented skin and mucosal changes with multiple endocrine and nonendocrine tumors, including the breast. Breast tumors are typically multiple and benign and are most commonly reported as myxoid fibroadenomas and/or intraductal papillomas. We present a young female patient with known CNC who presented with copious bloody nipple discharge with multiple breast lumps and discuss the breast imaging features regarding this complex and often underrecognized genetic condition.

Screening outcomes by risk factor and age: evidence from BreastScreen WA for discussions of risk-stratified population screening.

OBJECTIVES: To estimate rates of screen-detected and interval breast cancers, stratified by risk factor, to inform discussions of risk-stratified population screening. DESIGN: Retrospective population-based cohort study; analysis of routinely collected BreastScreen WA program clinical and administrative data. SETTING, PARTICIPANTS: All BreastScreen WA mammography screening episodes for women aged 40 years or more during 1 July 2007 - 30 June 2017. MAIN OUTCOME MEASURES: Cancer detection rate (CDR) and interval cancer rate (ICR), by risk factor. RESULTS: A total of 323 082 women were screened in 1 026 137 screening episodes (mean age, 58.5 years; SD, 8.6 years). The overall CDR was 68 (95% CI, 67-70) cancers per 10 000 screens, and the overall ICR was 9.7 (95% CI, 9.2-10.1) cancers per 10 000 women-years. Interactions between the effects on CDR of age group and five risk factors were statistically significant: personal history of breast cancer (P = 0.039), family history of breast cancer (P = 0.005), risk-relevant benign conditions (P = 0.012), hormone-replacement therapy (P = 0.002), and self-reported symptoms (P < 0.001). The influence of these risk factors (except personal history) increased with age. For ICR, only the interaction between age and hormone-replacement therapy was significant (P < 0.001), although weak interactions between age and family history of breast cancer or having dense breasts were noted (each P = 0.07). The influence of family history on ICR was significant only for women aged 40-49 years. CONCLUSIONS: Screening CDR and (for some risk factors) ICR were higher for women in some age groups with personal histories of breast cancer or risk-relevant benign breast conditions or first degree family history of breast cancer, women with dense breasts or self-reported breast-related symptoms, and women using hormone-replacement therapy. Our findings could inform the evaluation of risk-based screening.

Population screening detected non-lymphomatous non-mammary metastases to the breast. A radiology multimodality pictorial essay.

This pictorial essay is a presentation of imaging appearances of non-mammary cancer metastases to the breast detected in asymptomatic women attending BreastScreen Western Australia (BSWA) from 2005 to 2019. Haematological malignancies were excluded. Thirteen cases of histologically proven extramammary metastases to breast were identified from the BSWA data base. Five cases were ovarian cancer metastases, 3 melanoma metastases, 2 of adenocarcinoma metastases with foregut primary and one each of endometrial, renal and carcinoid metastases. Metastasis to breast commonly presented as circumscribed masses (N = 12) at mammography and as hypoechoic masses (N = 10) at ultrasound with a predilection to upper outer quadrant of breast. Metastases to breast from non-mammary primary while a rare occurrence in a breast screening program, may be the first clinical presentation of malignancy in asymptomatic women.

Post-mammographic screening behaviour: A survey investigating what women do after being told they have dense breasts.

ISSUE ADDRESSED: Despite widespread calls for women undergoing mammographic screening to be informed of their breast density, concerns remain as to how this is interpreted and acted upon given the absence of evidence-based supplemental screening recommendations for women with dense breasts. This study investigates the action women take in response to being notified they have dense breasts and what subsequent advice women receive from health professionals. METHODS: Via a survey of nearly 7000 women, we assessed the post-screening actions of women attending a population-based mammographic screening program (BreastScreen) in Western Australia from 21 November 2017 to 19 April 2018. Women who reported that they were notified they had dense breasts were compared to controls (where applicable). Descriptive and logistic regression analyses were used to summarise responses from 6,183 women. RESULTS: Half of women notified that they have dense breasts consulted or intended to consult their General Practitioner (GP), particularly those notified for the first time (55%). Of those notified women who consulted their GP, 50% were referred to have supplemental screening. Overall, 20% of women notified as having dense breasts reported that they had an ultrasound due to their breast density. CONCLUSION: Self-reported health service usage after mammographic screening is higher in women who have been notified they have dense breasts. So what? There is growing pressure for screening programs in Australia and internationally to routinely measure and report breast density to participants. Results from this study can inform screening programs of the likely impact of breast density notification on health service usage. While more information is needed to fill knowledge gaps in recommended action for women with dense breasts, the greatest risks to women arise from not being screened. Hence, health promotion practitioners and health providers should continue to encourage women to participate in BreastScreen programs.