Mammographic Screening in Routine Practice: Multisite Study of Digital Breast Tomosynthesis and Digital Mammography Screenings.

Background The use of digital breast tomosynthesis (DBT) is increasing over digital mammography (DM) following studies demonstrating lower recall rates (RRs) and higher cancer detection rates (CDRs). However, inconsistent interpretation of evidence on the risks and benefits of mammography has resulted in varying screening mammography recommendations. Purpose To evaluate screening outcomes among women in the United States who underwent routine DM or DBT mammographic screening. Materials and Methods This retrospective cohort study included women aged 40-79 years who underwent DM or DBT screening mammograms between January 2014 and December 2020. Outcomes of RR, CDR, positive predictive value of recall (PPV1), biopsy rate, and positive predictive value of biopsy (PPV3) were compared between DM and DBT with use of adjusted multivariable logistic regression models. Results A total of 2 528 063 screening mammograms from 1 100 447 women (mean age, 57 years ± 10 [SD]) were included. In crude analyses, DBT (1 693 727 screening mammograms vs 834 336 DM screening mammograms) demonstrated lower RR (10.3% [95% CI: 10.3, 10.4] for DM vs 8.9% [95% CI: 8.9, 9.0] for DBT; P < .001) and higher CDR (4.5 of 1000 screening mammograms [95% CI: 4.3, 4.6] vs 5.3 of 1000 [95% CI: 5.2, 5.5]; P < .001), PPV1 (4.3% [95% CI: 4.2, 4.5] vs 5.9% [95% CI: 5.7, 6.0]; P < .001), and biopsy rates (14.5 of 1000 screening mammograms [95% CI: 14.2, 14.7] vs 17.6 of 1000 [95% CI: 17.4, 17.8]; P < .001). PPV3 was similar between cohorts (30.0% [95% CI: 29.2, 30.9] for DM vs 29.3% [95% CI: 28.7, 29.9] for DBT; P = .16). After adjustment for age, breast density, site, and index year, associations remained stable with respect to statistical significance. Conclusion Women undergoing digital breast tomosynthesis had improved screening mammography outcomes compared with women who underwent digital mammography. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Bae and Seo in this issue.

Outcomes by Race in Breast Cancer Screening With Digital Breast Tomosynthesis Versus Digital Mammography.

PURPOSE: Digital breast tomosynthesis (DBT) in conjunction with digital mammography (DM) is becoming the preferred imaging modality for breast cancer screening compared with DM alone, on the basis of improved recall rates (RR) and cancer detection rates (CDRs). The aim of this study was to investigate racial differences in the utilization and performance of screening modality. METHODS: Retrospective data from 63 US breast imaging facilities from 2015 to 2019 were reviewed. Screening outcomes were linked to cancer registries. RR, CDR per 1,000 examinations, and positive predictive value for recall (cancers/recalled patients) were compared. RESULTS: A total of 385,503 women contributed 542,945 DBT and 261,359 DM screens. A lower proportion of screenings for Black women were performed using DBT plus DM (referred to as DBT) (44% for Black, 48% for other, 63% for Asian, and 61% for White). Non-White women were less likely to undergo more than one mammographic examination. RRs were lower for DBT among all women (8.74 versus 10.06, P < .05) and lower across all races and within age categories. RRs were significantly higher for women with only one mammogram. CDRs were similar or higher in women undergoing DBT compared with DM, overall (4.73 versus 4.60, adjusted P = .0005) and by age and race. Positive predictive value for recall was greater for DBT overall (5.29 versus 4.45, adjusted P < .0001) and by age, race, and screening frequency. CONCLUSIONS: All racial groups had improved outcomes with DBT screening, but disparities were observed in DBT utilization. These data suggest that reducing inequities in DBT utilization may improve the effectiveness of breast cancer screening.

Employer-perspective cost comparison of surgical treatments for abnormal uterine bleeding.

Aim: To estimate direct and indirect costs of surgical treatment of abnormal uterine bleeding (AUB) from a self-insured employer's perspective. Methods: Employer-sponsored insurance claims data were analyzed to estimate costs owing to absence and short-term disability 1 year following global endometrial ablation (GEA), outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH). Results: Costs for women who had GEA are substantially less than costs for women who had either OPH or IPH, with the difference ranging from approximately $7700 to approximately $10,000 for direct costs and approximately $4200 to approximately $4600 for indirect costs. Women who had GEA missed 21.8-24.0 fewer works days. Conclusion: Study results suggest lower healthcare costs associated with GEA versus OPH or IPH from a self-insured employer perspective.

Breast, Cervical, and Colorectal Cancer Screening: Patterns Among Women With Medicaid and Commercial Insurance.

INTRODUCTION: Despite healthcare reforms mandating expanded insurance coverage and reduced out-of-pocket costs for preventive care, cancer screening rates remain relatively static. No study has measured cancer screening rates for multiple tests among non-Medicare patients. METHODS: This retrospective, population-based claims analysis, conducted in 2016-2017, of commercially insured and Medicaid-insured women aged 30-59 years enrolled in IBM MarketScan Commercial and Medicaid Databases (containing approximately 90 and 17 million enrollees, respectively) during 2010-2015 describes screening rates for breast, cervical, and colorectal cancer. Key outcomes were (1) proportion screened for breast, cervical, and colorectal cancer among the age-eligible population compared with accepted age-based recommendations and (2) proportion with longer-than-recommended intervals between tests. RESULTS: One half (54.7%) of commercially insured women aged 40-59 years (n=1,538,444) were screened three or more times during the 6-year study period for breast cancer; for Medicaid-insured women (n=78,897), the rates were lower (23.7%). One third (43.4%) of commercially insured and two thirds (68.9%) of Medicaid-insured women had a >2.5-year gap between mammograms. Among women aged 30-59 years, 59.3% of commercially insured women and 31.4% of Medicaid-insured women received two or more Pap tests. The proportion of patients with a >3.5-year gap between Pap tests was 33.9% (commercially insured) and 57.1% (Medicaid-insured). Among women aged 50-59 years, 63.3% of commercially insured women and 47.2% of Medicaid-insured women were screened at least one time for colorectal cancer. Almost all women aged 30-59 years (commercially insured, 99.1%; Medicaid-insured, 98.9%) had at least one healthcare encounter. CONCLUSIONS: Breast and cervical cancer screenings remain underutilized among both commercially insured and Medicaid-insured populations, with lower rates among the Medicaid-insured population. However, almost all women had at least one healthcare encounter, suggesting opportunities for better coordinated care.

Comparison of Resource Utilization and Clinical Outcomes Following Screening with Digital Breast Tomosynthesis Versus Digital Mammography: Findings From a Learning Health System.

RATIONALE AND OBJECTIVES: To compare outcomes associated with breast cancer screening with digital mammography (DM) alone versus in combination with digital breast tomosynthesis (DBT) in a large representative cohort. MATERIALS AND METHODS: A total of 325,729 screening mammograms from 247,431 women were analyzed, across two healthcare systems, from June 2015 to September 2017. Patient level demographic, calculated risk levels, and clinical outcomes were extracted from radiology information system and electronic medical records. Multivariable regression modeling adjusting for institution, age, breast density, and first exam was conducted to compare patient characteristics, recall rates, time to biopsy and final diagnosis, clinical outcomes, and diagnostic performance. Participating institutions and the Coordinating Center received Institutional Review Board approval for a waiver of consent to collect and link data and perform analysis. RESULTS: A total of 194,437 (59.7%) screens were DBT versus 131,292 (40.3%) with DM. Women with dense breasts and higher calculated risk were more likely to be screened with DBT. Recall rates were lower for DBT overall (8.83% DBT vs 10.98% DM, adjusted odds ratio, 95% confidence interval = 0.85, 0.83-0.87) and across all age groups, races, and breast densities, and at facilities that used predominantly DBT (8.05%) versus predominantly DM (11.22%), or a combination (10.73%). The most common diagnostic pathway after recall was mammography and ultrasound. Women recalled from DBT were more likely to proceed directly to ultrasound. The median time to biopsy (18 vs 22 days) and final diagnosis (10 vs 13 days) was shorter for DBT. The adjusted cancer rate, cancer detection rate, and specificity were higher for DBT. CONCLUSION: DBT demonstrated a more efficient screening pathway and improved quality measures with lower recall rates in all patient types, reduced diagnostic mammography and shorter time to biopsy and final diagnosis.

Women with Newly Diagnosed Uterine Fibroids: Treatment Patterns and Cost Comparison for Select Treatment Options.

The primary objective of this study was to describe surgical treatment patterns among women with newly diagnosed uterine fibroids (UF). A secondary objective was to estimate the medical costs associated with other common surgical interventions for UF. Claims-based commercial and Medicare data (2011-2016) were used to identify women aged ≥30 years with continuous enrollment for at least 12 months before and after a new diagnosis of UF. Receipt of a surgical or radiologic procedure (hysterectomy, myomectomy, endometrial ablation, uterine artery embolization, and curettage) was the primary outcome. Health care resource utilization and costs were calculated for women with at least 12 months of continuous enrollment following a UF surgical procedure. Among women who met selection criteria, 31.7% of patients underwent a surgical procedure; 20.9% of these underwent hysterectomy. An increase was observed over time in the percentage of women undergoing outpatient hysterectomy (from 27.0% to 40.2%) and hysteroscopic myomectomy (from 8.0% to 11.5%). The cost analysis revealed that total health care costs for hysteroscopic myomectomy ($17,324) were significantly lower (P < 0.001) than those for women who underwent inpatient hysterectomy ($24,027) and those for women undergoing the 3 comparison procedures. Hysterectomy was the most common surgical intervention. Patients undergoing inpatient hysterectomy had the highest health care costs. Although less expensive, minimally invasive approaches are becoming more common; they are performed infrequently in patients with newly diagnosed UF. The results of this study may be useful in guiding decisions regarding the most appropriate and cost-effective surgical treatment for UF.

Economic Evaluation of Global Endometrial Ablation Versus Inpatient and Outpatient Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives.

Every year, abnormal uterine bleeding (AUB) exacts a heavy toll on women's health and leads to high costs for the US health care system. The literature shows that endometrial ablation results in fewer complications, shorter recovery and lower costs than more commonly performed hysterectomy procedures. The objective of this study was to model clinical-economic outcomes, budget impact, and cost-effectiveness of global endometrial ablation (GEA) versus outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH) procedures. A decision tree, state-transition (semi-Markov) economic model was developed to simulate 3 hypothetical cohorts of women who received surgical treatment for AUB (GEA, OPH, and IPH) over 1, 2, and 3 years to evaluate clinical and economic outcomes for GEA vs. OPH and GEA vs. IPH. Two versions of the model were created to reflect both commercial health care payer and US Medicaid perspectives, and analyses were conducted for both payer types. Total health care costs in the first year after GEA were substantially lower compared with those for IPH and OPH. Budget impact analysis results showed that increasing GEA utilization yields total annual cost savings of about $906,000 for a million-member commercial health plan and about $152,000 in cost savings for a typical-sized state Medicaid plan with 1.4 million members. Cost-effectiveness analysis results for both perspectives showed GEA as economically dominant (conferring greater benefit at lower cost) over both OPH and IPH in the 1-year commercial scenario. This study demonstrates that, for some patients, GEA may prove to be a safe, uterus-sparing, cost-effective alternative to OPH and IPH for the surgical treatment of AUB.

Value Analysis of Digital Breast Tomosynthesis for Breast Cancer Screening in a US Medicaid Population.

PURPOSE: Better understanding regarding the clinical-economic value of digital breast tomosynthesis (DBT) for breast cancer screening for Medicaid enrollees is needed to help inform sound, value-based decision making. The objective of this study was to conduct a clinical-economic value analysis of DBT for breast cancer screening among women enrolled in Medicaid to assess the potential clinical benefits, associated expenditures, and net budget impact of DBT. METHODS: Two annual screening mammography scenarios were evaluated with an economic model: (1) full-field digital mammography and (2) combined full-field digital mammography and DBT. The model focused on two main drivers of DBT value: (1) capacity for DBT to reduce the number of women recalled for additional follow-up imaging and diagnostic services and (2) capacity of DBT to facilitate earlier diagnosis of cancer at earlier stages, when treatment costs are lower. RESULTS: Model analysis results showed that the use of DBT as a mammographic screening modality by Medicaid enrollees potentially reduces the need for follow-up diagnostic services and improves the detection of invasive cancers, allowing earlier, less costly treatment. With the modest incremental reimbursement of $37 for DBT expected for a typical Medicaid claim, annual cost savings from DBT predicted by the model amounts to $8.14 per patient, potentially translating into more than $12,000 savings per year for an average-sized Medicaid plan and as much as $207,000 savings per year for a typical state Medicaid program. CONCLUSIONS: Wider adoption of DBT presents an opportunity to deliver value-based care to Medicaid programs and to help address disparities and barriers to accessing preventive care by some of the nation's most vulnerable citizens.

Evaluation of the NovaSure endometrial ablation procedure in women with uterine cavity length over 10 cm.

OBJECTIVE: To evaluate procedure-related adverse events, post-procedure menstrual bleeding status, and surgical re-intervention in women with a sounded uterine length > 10 cm compared to women with a sounded uterine length ≤ 10 cm who underwent the NovaSure endometrial ablation procedure. METHODS: We conducted a retrospective cohort study of 188 women from a Canadian community-based gynaecology practice. Eighty-seven women had a sounded uterine length > 10 cm, and 101 patients had a sounded length ≤ 10 cm. Procedure-related adverse events, post-procedure menstrual bleeding status, and surgical re-interventions were compared between groups. RESULTS: Mean uterine sounding lengths were 11.0 ± 0.6 cm and 8.9 ± 0.8 cm in the > 10 cm and ≤ 10 cm groups, respectively. There were no differences between the groups in demographic characteristics or gynaecologic history, with the exception of higher BMI in the > 10 cm group and a greater prevalence of dysmenorrhea in the ≤ 10 cm group. Overall, 44.1% of all participants had been unsuccessfully treated with hormonal therapy, and 20.7% had failed non-hormonal treatment before the ablation procedure. The remaining 35.2% of participants had declined alternative therapy and proceeded directly to endometrial ablation. No serious procedure-related adverse events occurred in either group. Menstrual bleeding status at follow-up at 30.4 ± 15.3 months (> 10 cm group) and 30.5 ± 15.5 months (≤ 10 cm group) was not different between the groups (P = 0.85). In women who did not undergo surgical re-intervention after the initial ablation, amenorrhea was reported by 51.9% in the > 10 cm group and 65.9% in the ≤ 10 cm group. CONCLUSION: The NovaSure endometrial ablation procedure was associated with successful menstrual bleeding outcomes in women with sounded uterine length > 10 cm. No serious procedure-related adverse events occurred, and the need for surgical re-intervention was low. There was no significant difference in bleeding rates between the > 10 cm and ≤ 10 cm uterine length cohorts.

Objectif : Comparer, chez des femmes ayant subi une ablation de l'endomètre au moyen de la technique NovaSure et présentant une longueur utérine déterminée par hystérométrie de plus de 10 cm ou de 10 cm ou moins, les événements indésirables associés à l'intervention, l'état des saignements menstruels à la suite de l'intervention et la nécessité de procéder à une nouvelle intervention chirurgicale. Méthodes : Nous avons mené une étude de cohorte rétrospective qui portait sur 188 femmes ayant fréquenté une pratique gynécologique communautaire au Canada. Quatre-vingt-sept de ces femmes présentaient une longueur utérine déterminée par hystérométrie de plus de 10 cm, tandis que les 101 autres présentaient une longueur utérine déterminée par hystérométrie de 10 cm ou moins. Les événements indésirables associés à l'intervention, l'état des saignements menstruels à la suite de l'intervention et la nécessité de procéder à une nouvelle intervention chirurgicale sont les paramètres qui ont été comparés chez ces deux groupes de femmes. Résultats : Les longueurs utérines moyennes déterminées par hystérométrie ont été de 11,0 ± 0,6 cm et de 8,9 ± 0,8 cm au sein des groupes « > 10 cm ¼ et « ≤ 10 cm ¼, respectivement. Aucune différence n'a été constatée entre les groupes en matière de caractéristiques démographiques ou d'antécédents gynécologiques, exception faite d'un IMC accru au sein du groupe « > 10 cm ¼ et d'une prévalence accrue de dysménorrhée au sein du groupe « ≤ 10 cm ¼. De façon globale, 44,1 % de toutes les participantes avaient connu l'échec de l'hormonothérapie et 20,7 % avaient connu l'échec d'un traitement non hormonal avant la tenue de l'ablation. Les participantes composant les autres 35,2 % avaient refusé d'avoir recours à un traitement de rechange et décidé de subir directement une ablation de l'endomètre. Aucun événement indésirable grave associé à l'intervention ne s'est manifesté dans l'un ou l'autre des groupes. Aucune différence n'a été constatée entre les groupes (P = 0,85) pour ce qui est de l'état des saignements menstruels au moment du suivi à 30,4 ± 15,3 mois (groupe « > 10 cm ¼) et à 30,5 ± 15,5 mois (groupe « ≤ 10 cm ¼). Chez les femmes qui n'ont pas eu à subir une nouvelle intervention chirurgicale à la suite de l'ablation initiale, une aménorrhée a été signalée par 51,9 % des participantes du groupe « > 10 cm ¼ et par 65,9 % des participantes du groupe « ≤ 10 cm ¼. Conclusion : La technique NovaSure d'ablation de l'endomètre a été associée à des issues réussies en matière de saignements menstruels chez les femmes présentant une longueur utérine déterminée par hystérométrie de plus de 10 cm. Aucun événement indésirable grave associé à l'intervention ne s'est manifesté et la nécessité de procéder à une nouvelle intervention chirurgicale était faible. Aucune différence significative n'a été constatée en matière de taux de saignement entre les groupes « > 10 cm ¼ et « ≤ 10 cm ¼.

Accuracy and anatomical coverage of perfusion CT assessment of the blood-brain barrier permeability: one bolus versus two boluses.

PURPOSE: To assess whether blood-brain barrier permeability (BBBP) values, extracted with the Patlak model from the second perfusion CT (PCT) contrast bolus, are significantly lower than the values extracted from the first bolus in the same patient. MATERIALS AND METHODS: 125 consecutive patients (29 with acute hemispheric stroke and 96 without stroke) who underwent a PCT study using a prolonged acquisition time up to 3 min were retrospectively identified. The Patlak model was applied to calculate the rate of contrast leakage out of the vascular compartment. Patlak plots were created from the arterial and parenchymal time enhancement curves obtained in multiple regions of interest drawn in ischemic brain tissue and in nonischemic brain tissue. The slope of a regression line fit to the Patlak plot was used as an indicator of BBBP. Square roots of the mean squared errors and correlation coefficients were used to describe the quality of the linear regression model. This was performed separately for the first and the second PCT bolus. Results from the first and the second bolus were compared in terms of BBBP values and the quality of the linear model fitted to the Patlak plot, using generalized estimating equations with robust variance estimation. RESULTS: BBBP values from the second bolus were not lower than BBBP values from the first bolus in either nonischemic brain tissue [estimated mean with 95% confidence interval: 1.42 (1.10-1.82) ml x 100 g(-1) x min(-1) for the first bolus versus 1.64 (1.31-2.05) ml x 100 g(-1) x min(-1) for the second bolus, p = 1.00] or in ischemic tissue [1.04 (0.97-1.12) ml x 100 g(-1) x min(-1) for the first bolus versus 1.19 (1.11-1.28) ml x 100 g(-1)min(-1) for the second bolus, p = 0.79]. Compared to regression models from the first bolus, the Patlak regression models obtained from the second bolus were of similar or slightly better quality. This was true both in nonischemic and ischemic brain tissue. CONCLUSION: The contrast material from the first bolus of contrast for PCT does not negatively influence measurements of BBBP values from the second bolus. The second bolus can thus be used to increase anatomical coverage of BBBP assessment using PCT.

Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke.

BACKGROUND AND PURPOSE: Different definitions have been proposed to define the ischemic penumbra from perfusion-CT (PCT) data, based on parameters and thresholds tested only in small pilot studies. The purpose of this study was to perform a systematic evaluation of all PCT parameters (cerebral blood flow, volume [CBV], mean transit time [MTT], time-to-peak) in a large series of acute stroke patients, to determine which (combination of) parameters most accurately predicts infarct and penumbra. METHODS: One hundred and thirty patients with symptoms suggesting hemispheric stroke < or =12 hours from onset were enrolled in a prospective multicenter trial. They all underwent admission PCT and follow-up diffusion-weighted imaging/fluid-attenuated inversion recovery (DWI/FLAIR); 25 patients also underwent admission DWI/FLAIR. PCT maps were assessed for absolute and relative reduced CBV, reduced cerebral blood flow, increased MTT, and increased time-to-peak. Receiver-operating characteristic curve analysis was performed to determine the most accurate PCT parameter, and the optimal threshold for each parameter, using DWI/FLAIR as the gold standard. RESULTS: The PCT parameter that most accurately describes the tissue at risk of infarction in case of persistent arterial occlusion is the relative MTT (area under the curve=0.962), with an optimal threshold of 145%. The PCT parameter that most accurately describes the infarct core on admission is the absolute CBV (area under the curve=0.927), with an optimal threshold at 2.0 ml x 100 g(-1). CONCLUSIONS: In a large series of 130 patients, the optimal approach to define the infarct and the penumbra is a combined approach using 2 PCT parameters: relative MTT and absolute CBV, with dedicated thresholds.