Breast Arterial Calcifications on Mammography: Awareness and Reporting Preferences Amongst Referring Physicians in Canada.

Purpose: Breast arterial calcifications (BAC) on mammography have been correlated with increased cardiovascular risk. The Canadian Society of Breast Imaging released a position statement on BAC reporting in January 2023. This study evaluates the awareness of the clinical significance of BAC and reporting preferences of referring physicians in Canada. Methods: A 15-question survey was distributed to Canadian physicians who may review mammography results via regional and subspecialty associations and on social media following local institutional ethical approval. Responses were collected over 10 weeks from February to April 2023. Results: Seventy-two complete responses were obtained. We are unable to determine the response rate, given the means of distribution. Only 17% (12/72) of responding physicians were previously aware of the association between BAC and increased cardiovascular risk, and 51% (37/72) preferred the inclusion of BAC in the mammography report. Fifty-six percent (40/72) indicated that BAC reporting would prompt further investigation, and 63% (45/72) would inform patients that their mammogram showed evidence of BAC. Sixty-nine percent (50/72) would find grading of BAC beneficial and 71% (51/72) agreed that there is a need for national guidelines. Conclusion: Less than a quarter of responding Canadian referring physicians were previously aware of the association between BAC and cardiovascular risk, although half of respondents indicated a preference for BAC reporting on mammography. Most participating physicians would inform their patients of the presence of BAC and consider further cardiovascular risk management. There was consensus that a national BAC grading system and clinical management guidelines would be beneficial.

Women in Radiology: Challenges and Opportunities.

Improving the status of women in radiology is crucial to better work environments. There is strong evidence in the business world that women leaders improve the workplace by making it more financially viable and by increasing collaboration, job satisfaction, and engagement. Diverse leadership fosters innovation, and women approach problem-solving with unique insights and collaborative styles. Gender diversity in leadership correlates with improved patient outcomes because women leaders prioritize patient-centered care and communication. Women create sustainable, productive work and improve radiology. Women serve as powerful role models, inspiring the next generation of women in radiology and addressing gender disparities. Increasing women leaders in radiology is essential to increase the number of women in radiology. This article summarizes many challenges women face when taking leadership roles: organizational biases prioritizing male viewpoints and marginalizing women's voices and contributions, a lack of role models, a lack of time ("second shift"), a lack of confidence, a lack of interest or perceived benefit, a lack of support, burnout, and previous poor experiences. While systemic issues are difficult to overcome, this article assists in the training and development of women radiologists by offering strategies to enhance job satisfaction and bring new and valuable perspectives to leadership.

Increasing Diversity in Canadian Radiology: From the Hiring Process to Needed Active Retention Efforts.

The Canadian Association of Radiologists supports equity, diversity, and inclusion (EDI) in employment. It is imperative that institutions implement recruitment and retention practices to ensure a diverse workforce. This requires considerable attention to each step in the process, including the job posting, candidate search, hiring committee composition, interviews, hiring decision, and retention and promotion. Job postings must be widely distributed and visible to underrepresented groups. The candidate search should be completed by a diverse committee with expertise in EDI. All committee members must complete EDI and anti-bias training and conduct a broad search that ensures underrepresented groups are encouraged to apply. Interviews must be offered to all candidates. The hiring decision must avoid the use of subjective criteria. Recruitment of members of underrepresented groups ensures a diverse workforce, and organizations should commit resources to the retention and promotion of these members. Mentorship programs must be implemented and incentives provided to faculty members to serve as mentors. Transparent guidelines for promotion made universally available on department or institution websites. Recruiting a diverse workforce in Medical Imaging will only be achieved if EDI are central to the organization's goals and strategic plan. All organizational policies, practices, and procedures must be reviewed with an intersectional lens to identify potential gaps, areas for improvement, and areas of strength in the recruitment and retention of members of underrepresented groups.

Auditing Abbreviated Breast MR Imaging: Clinical Considerations and Implications.

Abbreviated breast MR (AB-MR) imaging is a relatively new breast imaging tool, which maintains diagnostic accuracy while reducing image times compared with full-protocol breast MR (FP-MR) imaging. Breast imaging audits involve calculating individual and organizational metrics, which can be compared with established benchmarks, providing a standard against which performance can be measured. Unlike FP-MR imaging, there are no established benchmarks for AB-MR imaging but studies demonstrate comparable performance for cancer detection rate, positive predictive value 3, sensitivity, and specificity with T2. We review the basics of performing an audit, including strategies to implement if benchmarks are not being met.

Incidence of Breast Cancer in Younger Women: A Canadian Trend Analysis.

Purpose: Breast cancer (BC) incidence is increasing globally. Age-specific BC incidence trend analyses are lacking for women under age 50 in Canada. In this study, we evaluate the incidence trends in breast cancer in women under age 50 in Canada and compare them with corresponding trends among women 50 to 54. Methods: BC case counts were obtained from the National Cancer Incidence Reporting System (1984-1991) and the Canadian Cancer Registry (1992-2019) both housed at Statistics Canada. Population data were also obtained from Statistics Canada. Annual female BC age-specific incidence rates from 1984 to 2019 were derived for the following age groups: 20 to 29, 30 to 39, 40 to 49, 40 to 44, 45 to 49, and 50 to 54. Changes in trends in age-specific BC incidence rates, if any, and annual percent changes (APCs) for each identified trend, were determined using JoinPoint. Results: Statistically significant increasing trends in BC incidence rates were noted for almost all age groups: since 2001 for 20 to 29 (APC = 3.06%, P < .001); since 2009 for 30 to 39 (APC = 1.25%, P = .007); since 1984 for both 40 to 49 (APC = 0.26%, P < .001) and 40 to 44 (APC = 0.19%, P = .011), increased since 2015 for 40 to 49 (APC = 0.77%, P = .047); and since 2005 for 50 to 54 (APC = 0.38%, P = .022). Among women 45 to 49 there was a non-significant increase since 2005 (APC = 0.24, P = .058). Statistically significant average annualized increases in BC incidence rates were observed for each age group studied. Conclusions: Examining age-specific incidence rates formed a more complete picture of BC time trends with significant increasing trends in the incidence of BC among women in their 20s, 30s, 40s, and early 50s. A greater awareness regarding the increasing number of cases of BC in women younger than 50 is critical to allow for earlier diagnosis with its resultant reduced mortality and morbidity.

Breast Cancer Screening in the Intermediate-Risk Population: Falling Through the Cracks?

Breast cancer screening guidelines vary for women at intermediate risk (15%-20% lifetime risk) for developing breast cancer across jurisdictions. Currently available risk assessment models have differing strengths and weaknesses, creating difficulty and ambiguity in selecting the most appropriate model to utilize. Clarifying which model to utilize in individual circumstances may help determine the best screening guidelines to use for each individual.

Breast Magnetic Resonance Imaging for Preoperative Evaluation of Breast Cancer: A Systematic Review and Meta-Analysis.

Purpose: Preoperative breast magnetic resonance imaging (MRI) is known to detect additional cancers that are occult on mammography and ultrasound. There is debate as to whether these additional lesions affect clinical outcomes. The objective of this systematic review was to summarize the evidence on whether additional information on disease extent obtained with preoperative breast MRI in patients with newly diagnosed breast cancer affects surgical management, rates of recurrence, survival, re-excision, and early detection of bilateral cancer. Methods: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched until January 2021 (partial update July 2022) for studies comparing outcomes with versus without pre-operative MRI. Included were both randomized controlled trials and other comparative studies provided MRI and control groups had equivalent disease and patient characteristics or methods such as multivariable analysis or propensity score matching were used to control potential confounders. Results: The search resulted in 26,399 citations, of which 8 randomized control trials, 1 prospective cohort study, and 42 retrospective studies met the inclusion criteria. Use of MRI resulted in decreased rates of reoperations (OR = 0.73, 95% CI = 0.63 to 0.85), re-excisions (OR = 0.63, 95% CI = 0.45 to 0.89), and recurrence (HR = 0.77, 95% CI = 0.65 to 0.90). Increased detection of synchronous contralateral breast cancers led to a reduction in metachronous contralateral breast cancer (HR = 0.71, 95% CI = 0.59 to 0.85). Hazard ratios for recurrence-free and overall survival were 0.77 (95% CI = 0.53 to 1.12) and 0.89 (95% CI = 0.74 to 1.07). Conclusion: This systematic review indicates substantial benefits of pre-operative breast MRI in decreasing reoperations and recurrence.

Promoting Equity, Diversity, and Inclusion in Medicine: A Comprehensive Toolkit for Change in Radiology.

This toolkit presents a comprehensive framework for a toolkit intended to increase equity, diversity, and inclusion (EDI) within the medical field and recommendations. We advocate for clear, comprehensive definitions and interpretations of fundamental EDI terms, laying the groundwork necessary for initiating and maintaining EDI initiatives. Furthermore, we offer a systematic approach to establishing EDI committees within medical departments, accentuating the pivotal role these committees play as they drive and steer EDI strategies. This toolkit also explores strategies tailored for the recruitment of a diverse workforce. This includes integral aspects such as developing inclusive job advertisements, implementing balanced search methods for candidates, conducting unbiased appraisals of applications, and structuring diverse hiring committees. The emphasis on these strategies not only augments the diversity within medical institutions but also sets the stage for a more holistic approach to healthcare delivery. Therefore, by adopting the recommended strategies and guidelines outlined in this framework, medical institutions and specifically radiology departments can foster an environment that embodies inclusivity and equity, thereby enhancing the quality of patient care and overall health outcomes.

The Impact of Preoperative Breast MRI on Timing of Surgical Management in Newly Diagnosed Breast Cancer.

Purpose: Preoperative breast MRI has been recommended at our center since 2016 for invasive lobular carcinoma and cancers in dense breasts. This study examined how preoperative breast MRI impacted surgical timing and outcomes for patients with newly diagnosed breast cancer. Methods: Retrospective single-center study of consecutive women diagnosed with new breast cancer between June 1, 2019, and March 1, 2021, in whom preoperative breast MRI was recommended. MRI, tumor histology, breast density, post-MRI biopsy, positive predictive value of biopsy (PPV3), surgery, and margin status were recorded. Time from diagnosis to surgery was compared using t-tests. Results: There were 1054 patients reviewed, and 356 were included (mean age 60.9). Of these, 44.4% (158/356) underwent preoperative breast MRI, and 55.6% (198/356) did not. MRI referral was more likely for invasive lobular carcinoma, multifocal disease, and younger patients. Following preoperative MRI, 29.1% (46/158) patients required additional breast biopsies before surgery, for a PPV3 of 37% (17/46). The time between biopsy and surgery was 55.8 ± 21.4 days for patients with the MRI, compared to 42.8 ± 20.3 days for those without (P < .00001). MRI was not associated with the type of surgery (mastectomy vs breastconserving surgery) (P = .44) or rate of positive surgical margins (P = .52). Conclusion: Among patients who underwent preoperative breast MRI, we observed significant delays to surgery by almost 2 weeks. When preoperative MRI is requested, efforts should be made to mitigate associated delays.

Capturing the True Cost of Breast Cancer Treatment: Molecular Subtype and Stage-Specific per-Case Activity-Based Costing.

BACKGROUND: Breast cancer (BC) treatment is rapidly evolving with new and costly therapeutics. Existing costing models have a limited ability to capture current treatment costs. We used an Activity-Based Costing (ABC) method to determine a per-case cost for BC treatment by stage and molecular subtype. METHODS: ABC was used to proportionally integrate multidisciplinary evidence-based patient and provider treatment options for BC, yielding a per-case cost for the total duration of treatment by stage and molecular subtype. Diagnostic imaging, pathology, surgery, radiation therapy, systemic therapy, inpatient, emergency, home care and palliative care costs were included. RESULTS: BC treatment costs were higher than noted in previous studies and varied widely by molecular subtype. Cost increased exponentially with the stage of disease. The per-case cost for treatment (2023C$) for DCIS was C$ 14,505, and the mean costs for all subtypes were C$ 39,263, C$ 76,446, C$ 97,668 and C$ 370,398 for stage I, II, III and IV BC, respectively. Stage IV costs were as high as C$ 516,415 per case. When weighted by the proportion of molecular subtype in the population, case costs were C$ 31,749, C$ 66,758, C$ 111,368 and C$ 289,598 for stage I, II, III and IV BC, respectively. The magnitude of cost differential was up to 10.9 times for stage IV compared to stage I, 4.4 times for stage III compared to stage I and 35.6 times for stage IV compared to DCIS. CONCLUSION: The cost of BC treatment is rapidly escalating with novel therapies and increasing survival, resulting in an exponential increase in treatment costs for later-stage disease. We provide real-time, case-based costing for BC treatment which will allow for the assessment of health system economic impacts and an accurate understanding of the cost-effectiveness of screening.

Impact of Breast Cancer Screening on 10-Year Net Survival in Canadian Women Age 40-49 Years.

PURPOSE: In Canada, some provincial/territorial mammography screening programs include women age 40-49 years, whereas others do not. This study examines the impact of this dichotomy on the 10-year breast cancer (BC) net survival (NS) among women age 40-49 years and 50-59 years at diagnosis. METHODS: Using the Canadian Cancer Registry data record linked to death information, we evaluated the cohort of Canadian women age 40-49 years and 50-59 years diagnosed with BC from 2002 to 2007. We compared 10-year NS estimates in the jurisdictions with organized screening programs that included women age 40-49 years, designated as screeners (Northwest Territories, British Columbia, Alberta, Nova Scotia, and Prince Edward Island), with comparator programs that did not (Yukon, Manitoba, Saskatchewan, Ontario, Quebec, New Brunswick, and Newfoundland and Labrador). RESULTS: BC was the primary cause of 10-year mortality in women age 40-49 years diagnosed with BC (90.7% of deaths). Among these women, the 10-year NS for screeners (84.8%; 95% CI, 83.8 to 85.8) was 1.9 percentage points (pp) higher than that for comparators (82.9%; 95% CI, 82.3 to 83.5; P = .001). The difference in favor of screeners was significant among women age 45-49 years (2.6 pp; P = .001) but not among women age 40-44 years (0.9 pp; P = .328). Similarly, the incidence-based BC mortality rate was significantly lower in screener jurisdictions among women age 40-49 years and 45-49 years, but not for 40-44 years. Provincial/territorial NS increased significantly with higher mammography screening participation (P = .003). The BC incidence rate was virtually identical in screener and comparator jurisdictions among women age 40-49 years (P = .976) but was significantly higher for comparators among women age 50-59 years (P < .001). CONCLUSION: Screening programs that included women in their 40s were associated with a significantly higher BC 10-year NS in women age 40-49 years, but not an increased rate of BC diagnosis. These results may inform screening guidelines for women age 40-49 years.

Medico-Legal Cases in Breast Imaging in Canada: A Trend Analysis.

Purpose: Breast imaging accounts for a large proportion of medico-legal cases involving radiologists in several countries and may be a disincentive to breast imaging. As this has not been well studied in Canada, we evaluated the key medico-legal issues of breast imaging in Canada and their implications for health care providers and patient safety. Methods: In collaboration with Canadian Medical Protective Association (CMPA), we obtained information from the medico-legal repository, including civil-legal, medical regulatory authority (College) and hospital complaints occurring between 2002-2021. Canadian Classification of Health Interventions (CCI) codes were used for breast imaging and biopsy. Trend analysis was done comparing cases involving breast imaging/biopsy to all cases where a radiologist was named. Results: Radiologists were named in 3108 medico-legal cases, 188 (6%, 188/3108) of which were CCI coded for breast imaging or biopsy. Factors related to radiologists were most frequent (64%, 120/188), followed by team (23.4%, 44/188) and system (6.9%, 13/188). Equal representation of male and female radiologists was found (IRR = 1.22; 95% CI: .89, 1.56). In a 10-year test window from 2006 - 2015 we identified an increasing trend for all cases involving radiologists (P = 0,0128) but a decreasing trend for cases coded with breast imaging or biopsy (P = 0,0099). Conclusions: A significant decrease in cases involving breast imaging were found from 2006-2015, accounting for 6% of the medico-legal cases. The lower risk of breast imaging medico-legal issues may encourage more radiologists in breast imaging.

Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline.

BACKGROUND: The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent. METHODS: After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic. RESULTS: Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

Progress and Remaining Gaps in the Early Detection and Treatment of Breast Cancer.

Breast cancer affects too many of us [...].

Addressing Misinformation About the Canadian Breast Screening Guidelines.

Screening mammography has been shown to reduce breast cancer mortality by 41% in screened women ages 40-69 years. There is misinformation about breast screening and the Canadian breast screening guidelines. This can decrease confidence in screening mammography and can lead to suboptimal recommendations. We review some of this misinformation to help radiologists and referring physicians navigate the varied international and provincial guidelines. We address the ages to start and stop breast screening. We explore how these recommendations may vary for specific populations such as patients who are at increased risk, transgender patients and minorities. We identify who would benefit from supplemental screening and review the available supplemental screening modalities including ultrasound, MRI, contrast-enhanced mammography and others. We describe emerging technologies including the potential use of artificial intelligence for breast screening. We provide background on why screening policies vary across the country between provinces and territories. This review is intended to help radiologists and referring physicians understand and navigate the varied international and provincial recommendations and guidelines and make the best recommendations for their patients.

Does Double Reading of Screening Breast MRI Scans Impact Recall Rates and Cancer Detection?

Objective: To investigate the effect of double reads by a second radiologist on cancer detection rate (CDR), positive predictive value of recommendation for tissue diagnosis (PPV2), and the positive predictive value of biopsy performed (PPV3) for biopsy recommendations in high-risk screening breast MRIs. Methods: The policy of second reads on biopsies recommended for MRIs was prospectively implemented in October 2019. This IRB approved retrospective analysis compared consecutive high-risk screening breast MRI scans performed in a single academic institution between 06/01/2018 to 06/01/2019 (pre-intervention) with screening breast MRI scans performed between 10/31/2019 to 10/31/2020 (post-intervention). Pathology results after biopsy were recorded. Testing of association was performed using the Chi-square test. Results/Discussion: A total of 1124 screening breast MRIs in the pre-intervention and 1672 screening breast MRIs were performed in the post-intervention periods. Biopsies were recommended in 8.6% (97/1124) of pre-intervention and 5.5% (92/1672) of post-intervention MRIs (P = .0012). There was a non-significant increase in PPV2 from pre-intervention 10.3% (10/97) to post-intervention 18.4% (17/92) (P = .109) and in PPV3 from 14% (10/71) to 22.9% (17/74), respectively (P = .17). Similar cancer detection rates, 8.9/1000 (10/1124) and 10.2/1000 (17/1672) (P = .736) were diagnosed in pre-intervention and post-intervention periods, respectively. Conclusion: Double reading of screening breast MRI scans significantly reduced the number of unnecessary biopsies without significant impact in the PPVs or cancer detection rate.

Correlation Between Breast Arterial Calcifications and Higher Cardiovascular Risk: Awareness and Attitudes Amongst Canadian Radiologists Who Report Mammography.

Background: Breast arterial calcification (BAC) on mammography correlates with increased cardiovascular risk. Reporting BAC is not standard practice. Our study evaluates the awareness of Canadian radiologists who report mammography of the clinical significance of BAC and their attitudes towards reporting BAC compared to their European and American counterparts. Methods: Following local institutional ethics approval, a 25 question survey (SurveyMonkey) was disseminated to Canadian radiologists via provincial and national society email lists. Responses were collected over 5 weeks (April-June 2022). Results: One hundred and eighty-six complete responses were collected. Sixty percent (112/186) were aware of the association between BAC and cardiovascular risk and 16% (29/186) document its presence in mammogram reports. Thirty five percent (65/186) occasionally document BAC if severe or in a young patient. Four percent (7/186) had local departmental guidelines on BAC reporting and 82% (153/186) agreed there is a need for national BAC reporting guidelines. Fewer Canadian radiologists were aware of the association between BAC and cardiovascular risk compared to European radiologists (60% vs 81%), report the presence of BAC compared to both European (15% vs 62%) and American (15% vs 35%) radiologists, and inform the patient of the presence of BAC compared to European radiologists (1% vs 46%). Conclusion: Canadian radiologists who report mammography were less aware of the association between BAC and cardiovascular risk than their European and American counterparts and were less likely to document the presence of BAC. Given the correlation of BAC with increased cardiovascular event risk, there is increased need for awareness as well as national BAC reporting guidelines.

Feasibility Study and Clinical Impact of Incorporating Breast Tissue Density in High-Risk Breast Cancer Screening Assessment.

Breast tissue density (BTD) is known to increase the risk of breast cancer but is not routinely used in the risk assessment of the population-based High-Risk Ontario Breast Screening Program (HROBSP). This prospective, IRB-approved study assessed the feasibility and impact of incorporating breast tissue density (BTD) into the risk assessment of women referred to HROBSP who were not genetic mutation carriers. All consecutive women aged 40-69 years who met criteria for HROBSP assessment and referred to Genetics from 1 December 2020 to 31 July 2021 had their lifetime risk calculated with and without BTD using Tyrer-Cuzick model version 8 (IBISv8) to gauge overall impact. McNemar's test was performed to compare eligibility with and without density. 140 women were referred, and 1 was excluded (BRCA gene mutation carrier and automatically eligible). Eight of 139 (5.8%) never had a mammogram, while 17/131 (13%) did not have BTD reported on their mammogram and required radiologist review. Of 131 patients, 22 (16.8%) were clinically impacted by incorporation of BTD: 9/131 (6.9%) became eligible for HROBSP, while 13/131 (9.9%) became ineligible (p = 0.394). It was feasible for the Genetics clinic to incorporate BTD for better risk stratification of eligible women. This did not significantly impact the number of eligible women while optimizing the use of high-risk supplemental MRI screening.