Time trend analysis and impacts of the COVID-19 pandemic on mammography and Papanicolaou test coverage in Brazilian state capitals.

BACKGROUND: Breast and cervical cancer are major public health issues globally. The reduction in incidence and mortality rates of these cancers is linked to effective prevention, early detection, and appropriate treatment measures. This study aims to analyze the temporal trends in the prevalence of mammography and Papanicolaou test coverage among women living in Brazilian state capitals between 2007 and 2023, and to compare the coverage of these tests before and during the Covid-19 pandemic. METHODS: A time series study was conducted using data from the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey from 2007 to 2023. The variables analyzed included mammography and Papanicolaou test coverage according to education level, age group, race/skin color, regions, and Brazilian capitals. The Prais-Winsten regression model was used to analyze the time series, and Student's t-test was employed to compare the prevalence rates between 2019 and 2023. RESULTS: Between 2007 and 2023, mammography coverage showed a stationary trend (71.1% in 2007 and 73.1% in 2023; p-value = 0.75) with a declining trend observed among women with 12 years or more of education (APC= -0.52% 95%CI -1.01%; -0.02%). Papanicolaou test coverage for all women aged between 25 and 64 exhibited a downward trend from 82% in 2007 to 76.8% in 2023 (APC= -0.45% 95%CI -0.76%; -0.13%). This decline was also noticed among those with 9 years or more of education; in the 25 to 44 age group; among women with white and mixed race; and in the Northeast, Central-West, Southeast, and South regions. When comparing coverage before and during Covid-19 pandemic, a reduction was noted for both tests. CONCLUSIONS: Over the years, there has been stability in mammography coverage and a decline in Papanicolaou test. The COVID-19 pandemic negatively impacted the number of these tests carried out among women, highlighting the importance of actions aimed at increasing coverage, especially among the most vulnerable groups.

[New recommendations on mammography screening for women over 70 years]. / Le nuove raccomandazioni sullo screening mammografico per le donne con più di 70 anni.

The new recommendations of the European Council (December 2022) indicate to the Member States to implement mammography screening programs for women aged 45 to 74 and make explicit reference to the European guidelines produced by the ECIBC (European Commission Initiative on Breast Cancer) for operational indications. For women aged 70-74, the ECIBC suggests a three-year interval, rather than two years, and the process of adaptation and adoption of the guidelines in Italy has taken this recommendation as it is. Previous indications for Italian screening programs proposed a two-year interval for all women over 50 years of age. The intervention analyzes the rationale and interpretation of the evidence that led to the formulation of the different recommendations. It discusses whether the new recommendations fit into the perspective of risk-stratified screening that is under evaluation by several studies. it analyzes some of the critical issues of the methodology for developing recommendations in defining the characteristics of complex interventions, in particular the difficulties that the formulation of dichotomous questions finds in answering questions such as what is the best age to stop screening and what is the best interval at any age, which require an analysis of a continuous variable as age or interval duration. Finally, the opportunities and limitations in producing evidence regarding the best interval to adopt in mammography screening are discussed.

Urbanicity, Income, and Mammography-Use Disparities Among American Indian Women.

INTRODUCTION: Reported breast cancer screening among American Indian women is consistently below that of White women. The last claims-based trends were from 1991 to 2001. This study updates mammography trends for American Indian women and examines the impact of race, urbanicity, and income on long-term mammography use. METHODS: This was a multi-year (2005-2019), retrospective study of women aged 40-89 years using a 5% sample of Medicare fee-for-service beneficiaries residing in Arizona, California, New Mexico, Oklahoma, and Washington. This study used multivariable logistic regression to examine the impact of urbanicity and income on receiving mammography for American Indian women compared with that for White women. Analyses were conducted in 2022. RESULTS: Overall, annual age-adjusted mammography use declined from 205 per 1,000 in 2005 to 165 per 1,000 in 2019. The slope of these declines was significantly steeper (difference = -2.41, p<0.001) for White women (-3.06) than for American Indian women (-0.65). Mammography-use odds across all urbanicity categories were less for American Indian women than for White women compared with those of their respective metropolitan counterparts (e.g., rural: 0.96, 95% CI=0.77, 1.20 for American Indian women and 1.47, 99% CI=1.39, 1.57 for White women). Although residing in higher-income communities was not associated with mammography use for American Indian women, it was 31% higher for White women (OR=1.31, 99% CI=1.28, 1.34). CONCLUSIONS: The disparity in annual age-adjusted mammography use between American Indian and White women narrowed between 2005 and 2019. However, the association of urbanicity and community income on mammography use differs substantially between American Indian and White women. Policies to reduce disparities need to consider these differences.

Trends in breast cancer screening rates among Korean women: results from the Korean National Cancer Screening Survey, 2005-2020.

OBJECTIVES: Since 2002, the Korean government has provided breast cancer screening as part of the National Cancer Screening Program. This study reported trends in the screening rate among Korean women from 2005 to 2020, including organized and opportunistic screening for breast cancer. METHODS: Data from the Korean National Cancer Screening Survey, an annual cross-sectional nationwide survey, were collected using a structured questionnaire between 2005 and 2020. The study population included 23,702 women aged 40-74 years with no history of cancer. We estimated the screening rate based on the current recommendation of biennial mammographic screening for breast cancer. In addition, a joinpoint trend analysis was performed for breast cancer screening rates among various subgroups. RESULTS: In 2020, the breast cancer screening rate was 63.5%, reflecting an annual increase of 7.72% (95% confidence interval 5.53 to 9.95) between 2005 and 2012, followed by non-significant trends thereafter. In particular, a significant decrease in the breast cancer screening rate was observed in the subgroups aged 50-59 years old, with 12-15 years of education, and living in rural areas. CONCLUSIONS: Although there has been substantial improvement in breast cancer screening rates in Korean women, the trend has flattened in recent years. Therefore, continual efforts are required to identify subgroups with unmet needs and solve barriers to the uptake of breast cancer screening.

Utilidad clínica de la mamografía con contraste (CEM): una revisión de la literatura / Clinical utility of contrast-enhanced mammography: A literature review

La mamografía con contraste (CEM) es una nueva y prometedora técnica de imagen basada en la neovascularización de los tumores de manera similar a la resonancia magnética de la mama. Los resultados de los estudios clínicos muestran que su rendimiento diagnóstico es significativamente mejor que el de la mamografía digital convencional, y que sus valores de sensibilidad y especificidad la hacen comparable con la resonancia magnética. Sus usos actuales y los propuestos incluyen la evaluación adicional de pacientes sintomáticos o pacientes con exámenes previos anormales, la evaluación de la extensión local de los cánceres de mama recién diagnosticados, el seguimiento de la quimioterapia neoadyuvante y la detección del cáncer de mama en pacientes de alto riesgo. Aunque la técnica se aprobó para uso clínico en 2010, todavía es poco conocida. En esta revisión, presentamos la técnica CEM y sus resultados de rendimiento de diagnóstico comparados con la mamografía convencional y la resonancia magnética de la mama. También presentamos los diferentes escenarios en los que se puede utilizar con éxito, tanto en el diagnóstico de la enfermedad de mama, como en la estadificación local del cáncer de mama, así como su papel potencial en los programas de detección del cáncer de mama. (AU)

Contrast-enhanced mammography (CEM) is a promising new imaging technique based on neovascularisation of the tumour, similar to magnetic resonance imaging of the breast. The results of clinical studies show that its diagnostic performance is significantly better than that of conventional digital mammography, and that its sensitivity and specificity are comparable to those of magnetic resonance imaging. Its current and proposed uses include further evaluation of symptomatic patients or patients with abnormal results on previous examinations, assessment of the local extension of newly diagnosed breast tumours, follow-up of neoadjuvant chemotherapy and detection of breast cancer in high-risk patients. Although the technique was approved for clinical use in 2010, it is still little known. In this review, we present the technique of CEM and its results in terms of diagnostic performance compared with conventional mammography and breast MRI. We also discuss the various scenarios in which it can be used successfully, both in the diagnosis of breast disease and in the local staging of breast cancer, as well as its potential role in breast cancer screening programmes. (AU)

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021.

Importance: Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. Objective: To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. Design, Setting, and Participants: In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Exposures: Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Main Outcomes and Measures: Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. Results: More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Conclusions and Relevance: Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

The development of breast radiology: the Acta Radiologica perspective.

The encouraging results of modern breast cancer care builds on tremendous improvements in diagnostics and therapy during the 20th century. Scandinavian countries have made important footprints in the development of breast diagnostics regarding technical development of imaging, cell and tissue sampling methods and, not least, population screening with mammography. The multimodality approach in combination with multidisciplinary clinical work in breast cancer serve as a role model for the management of many cancer types worldwide. The development of breast radiology is well represented in the research published in this journal and this historical review will describe the most important steps.

Contrast-enhanced Mammography: State of the Art.

Contrast-enhanced mammography (CEM) has emerged as a viable alternative to contrast-enhanced breast MRI, and it may increase access to vascular imaging while reducing examination cost. Intravenous iodinated contrast materials are used in CEM to enhance the visualization of tumor neovascularity. After injection, imaging is performed with dual-energy digital mammography, which helps provide a low-energy image and a recombined or iodine image that depict enhancing lesions in the breast. CEM has been demonstrated to help improve accuracy compared with digital mammography and US in women with abnormal screening mammographic findings or symptoms of breast cancer. It has also been demonstrated to approach the accuracy of breast MRI in preoperative staging of patients with breast cancer and in monitoring response after neoadjuvant chemotherapy. There are early encouraging results from trials evaluating CEM in the screening of women who are at an increased risk of breast cancer. Although CEM is a promising tool, it slightly increases radiation dose and carries a small risk of adverse reactions to contrast materials. This review details the CEM technique, diagnostic and screening uses, and future applications, including artificial intelligence and radiomics.

Google search volume trends for cancer screening terms during the COVID-19 pandemic.

The COVID-19 pandemic has led to delays in cancer diagnosis, in part due to postponement of cancer screening. We used Google Trends data to assess public attention to cancer screening during the first peak of the COVID-19 pandemic. Search volume for terms related to established cancer screening tests ("colonoscopy," "mammogram," "lung cancer screening," and "pap smear") showed a marked decrease of up to 76% compared to the pre-pandemic period, a significantly greater drop than for search volume for terms denoting common chronic diseases. Maintaining awareness of cancer screening during future public health crises may decrease delays in cancer diagnosis.

Robust breast cancer detection in mammography and digital breast tomosynthesis using an annotation-efficient deep learning approach.

Breast cancer remains a global challenge, causing over 600,000 deaths in 2018 (ref. 1). To achieve earlier cancer detection, health organizations worldwide recommend screening mammography, which is estimated to decrease breast cancer mortality by 20-40% (refs. 2,3). Despite the clear value of screening mammography, significant false positive and false negative rates along with non-uniformities in expert reader availability leave opportunities for improving quality and access4,5. To address these limitations, there has been much recent interest in applying deep learning to mammography6-18, and these efforts have highlighted two key difficulties: obtaining large amounts of annotated training data and ensuring generalization across populations, acquisition equipment and modalities. Here we present an annotation-efficient deep learning approach that (1) achieves state-of-the-art performance in mammogram classification, (2) successfully extends to digital breast tomosynthesis (DBT; '3D mammography'), (3) detects cancers in clinically negative prior mammograms of patients with cancer, (4) generalizes well to a population with low screening rates and (5) outperforms five out of five full-time breast-imaging specialists with an average increase in sensitivity of 14%. By creating new 'maximum suspicion projection' (MSP) images from DBT data, our progressively trained, multiple-instance learning approach effectively trains on DBT exams using only breast-level labels while maintaining localization-based interpretability. Altogether, our results demonstrate promise towards software that can improve the accuracy of and access to screening mammography worldwide.

Current Status and Future of BI-RADS in Multimodality Imaging, From the AJR Special Series on Radiology Reporting and Data Systems.

BI-RADS is a communication and data tracking system that has evolved since its inception as a brief mammography lexicon and reporting guide into a robust structured reporting platform and comprehensive quality assurance tool for mammography, ultrasound, and MRI. Consistent and appropriate use of the BI-RADS lexicon terminology and assessment categories effectively communicates findings, estimates the risk of malignancy, and provides management recommendations to patients and referring clinicians. The impact of BI-RADS currently extends internationally through six language translations. A condensed version has been proposed to facilitate a phased implementation of BI-RADS in resource-constrained regions. The primary advance of the 5th edition of BI-RADS is harmonization of the lexicon terms across mammography, ultrasound, and MRI. Harmonization has also been achieved across these modalities for the reporting structure, assessment categories, management recommendations, and data tracking system. Areas for improvement relate to certain common findings that lack lexicon descriptors and a need for further clarification of proper use of category 3. BI-RADS is anticipated to continue to evolve for application to a range of emerging breast imaging modalities.

Cribado en pacientes con riesgo incrementado de cáncer de mama (parte 1). Pros y contras del cribado con resonancia magnética / Screening in patients with increased risk of breast cancer (part 1): pros and cons of MRI screening

En mujeres con alto riesgo de padecer cáncer de mama, la detección precoz tiene un importante papel. Debido a la alta incidencia de cáncer mamario y a edades más tempranas que en la población general, se recomienda que el cribado comience en edad más joven, y existe amplia evidencia de que la resonancia magnética es la herramienta diagnóstica más sensible: las principales guías americanas y europeas coinciden en la recomendación de realizar resonancia magnética anual (con mamografía anual suplementaria) como modalidad óptima de cribado. No obstante, no hay un total consenso actual entre las guías sobre algunos subgrupos de pacientes a incluir en la recomendación de cribado con resonancia magnética. El objetivo de esta primera parte de nuestro trabajo es, mediante una revisión de la bibliografía, explicar y valorar las ventajas que este tipo de cribado con resonancia magnética proporciona respecto al cribado solo con mamografía, como son: mayor detección de cánceres de menor tamaño y con menor afectación ganglionar asociada y una reducción de los cánceres de intervalo, lo que puede tener repercusión en supervivencia y mortalidad, con efectos comparables a otras medidas de prevención. Pero, a su vez, también queremos reflejar los inconvenientes que el cribado con resonancia magnética conlleva, y que dificultan su aplicabilidad

Screening plays an important role in women with a high risk of breast cancer. Given this population's high incidence of breast cancer and younger age of onset compared to the general population, it is recommended that screening starts earlier. There is ample evidence that magnetic resonance imaging (MRI) is the most sensitive diagnostic tool, and American and the European guidelines both recommend annual MRI screening (with supplementary annual mammography) as the optimum screening modality. Nevertheless, the current guidelines do not totally agree about the recommendations for MRI screening in some subgroups of patients. The first part of this article on screening in women with increased risk of breast cancer reviews the literature to explain and evaluate the advantages of MRI screening compared to screening with mammography alone: increased detection of smaller cancers with less associated lymph node involvement and a reduction in the rate of interval cancers, which can have an impact on survival and mortality (with comparable effects to other preventative measures). At the same time, however, we would like to reflect on the drawbacks of MRI screening that affect its applicability

Stand-alone artificial intelligence - The future of breast cancer screening?

Although computers have had a role in interpretation of mammograms for at least two decades, their impact on performance has not lived up to expectations. However, in the last five years, the field of medical image analysis has undergone a revolution due to the introduction of deep learning convolutional neural networks - a form of artificial intelligence (AI). Because of their considerably higher performance compared to conventional computer aided detection methods, these AI algorithms have resulted in renewed interest in their potential for interpreting breast images in stand-alone mode. For this, first the actual capability of the algorithms, compared to breast radiologists, needs to be well understood. Although early studies have pointed to the comparable performance between AI systems and breast radiologists in interpreting mammograms, these comparisons have been performed in laboratory conditions with limited, enriched datasets. AI algorithms with performance comparable to breast radiologists could be used in a number of different ways, the most impactful being pre-selection, or triaging, of normal screening mammograms that would not need human interpretation. Initial studies evaluating this proposed use have shown very promising results, with the resulting accuracy of the complete screening process not being affected, but with a significant reduction in workload. There is a need to perform additional studies, especially prospective ones, with large screening data sets, to both gauge the actual stand-alone performance of these new algorithms, and the impact of the different implementation possibilities on screening programs.

[Artificial intelligence in the diagnosis of breast cancer : Yesterday, today and tomorrow]. / Künstliche Intelligenz in der Mammadiagnostik : Gestern, heute und morgen.

BACKGROUND: Artificial intelligence (AI) is increasingly applied in the field of breast imaging. OBJECTIVES: What are the main areas where AI is applied in breast imaging and what AI and computer-aided diagnosis (CAD) systems are already available? MATERIALS AND METHODS: Basic literature and vendor-supplied information are screened for relevant information, which is then pooled, structured and discussed from the perspective of breast imaging. RESULTS: Original CAD systems in mammography date almost 25 years back. They are much more widely applied in the United States than in Europe. The initial CAD systems exhibited limited diagnostic abilities and disproportionally high rates of false positive results. Since 2012, deep learning mechanisms have been applied and expand the application possibilities of AI. CONCLUSION: To date there is no algorithm that has beyond doubt been proven to outperform double reporting by two certified breast radiologists. AI could, however, in the foreseeable future, take over the following tasks: preselection of abnormal examinations to substantially reduce workload of the radiologists by either excluding normal findings from human review or by replacing the double reader in screening. Furthermore, the establishment of radio-patho-genomic correlations and their translation into clinical practice is hardly conceivable without AI.

Double reading in breast cancer screening: considerations for policy-making.

In this article, we explore the evidence around the relative benefits and harms of breast cancer screening using a single radiologist to examine each female's mammograms for signs of cancer (single reading), or two radiologists (double reading). First, we briefly explore the historical evidence using film-screen mammography, before providing an in-depth description of evidence using digital mammography. We classify studies according to which exact version of double reading they use, because the evidence suggests that effectiveness of double reading is contingent on whether the two radiologists are blinded to one another's decisions, and how the decisions of the two radiologists are integrated. Finally, we explore the implications for future mammography, including using artificial intelligence as the second reader, and applications to more complex three-dimensional imaging techniques such as tomosynthesis.

Utilization of Screening Mammograms in the Medicare Population Before and After the Affordable Care Act Implementation.

Objective: This study examined screening mammograms in women aged 65 to 74 years and 75+ years before and after the Affordable Care Act (ACA) implementation. Method: This repeated cross-sectional study of community-dwelling women age 65+ years without a history of breast cancer or mastectomy utilized the Medicare Current Beneficiary Survey and Medicare fee-for-service claims data from 2001 to 2013. We used covariate-adjusted logistic regression with generalized estimating equations, stratified by age group. Results: The adjusted odds of screening mammograms in women aged 65-74 (n = 742) and 75+ years (n = 681) were lower in 2013 (odds ratio [OR]: 0.75, 95% confidence interval [CI]: [0.67, 0.83]; OR: 0.67, 95% CI: [0.60, 0.75], respectively) than the odds of screening mammograms in 2001. Discussion: Annual screening mammograms decreased in women aged 65 to 74 years and 75+ years, despite increased access from the ACA implementation. Future research as to why women are no longer receiving screening mammograms, such as changes in physician specialty guidelines, is warranted.

[Breast cancer: News tools in imaging]. / Cancer du sein : la nouvelle imagerie.

Breast cancer imaging is always improving for the last 20 years in spite of digitalization and computer development. News tools in mammography (Digital Breast Tomosynthesis, Contrast enhanced mammography), sonography (elastography, Automated echography), MRI (Diffusion, abbreviated MRI) and Nuclear medicine has the great potential to be the future of breats imaging. But true revolution will be to use the huge volume of "hidden" imaging data, by Intelligence Artificial process or Biological progress (in genomics, proteiomics) to purpose to our patient a personalized imaging.