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1.
Artigo em Inglês | MEDLINE | ID: mdl-34078641

RESUMO

BACKGROUND: Previous reports suggested risk of death and breast cancer varied by comorbidity and age in older women undergoing mammography. However, impacts of functional limitations remain unclear. METHODS: We used data from 238,849 women in the Breast Cancer Surveillance Consortium-Medicare linked database (1999-2015) who had screening mammogram at ages 66-94 years. We estimated risk of breast cancer, breast cancer death, and non-breast cancer death by function-related indicator (FRI) which incorporated 16 claims-based items and was categorized as an ordinal variable (0,1,and 2+). Fine and Gray proportional sub-distribution hazards models were applied with breast cancer and death treated as competing events. Risk estimates by FRI scores were adjusted by age and NCI comorbidity index separately and stratified by these factors. RESULTS: Overall, 9,252 women were diagnosed with breast cancer, 406 died of breast cancer, and 41,640 died from non-breast cancer causes. The 10-year age-adjusted invasive breast cancer risk slightly decreased with FRI score (FRI=0:4.0%, 95% CI=3.8%-4.1%; FRI=1:3.9%, 95% CI=3.7%-4.2%; FRI{greater than or equal to}2:3.5%, 95% CI=3.1%-3.9%). Risk of non-breast cancer death increased with FRI score (FRI=0:18.8%, 95% CI=18.5%-19.1%; FRI=1:24.4%, 95% CI=23.9%-25.0%; FRI{greater than or equal to}2:39.8%, 95% CI=38.8%-40.9%). Risk of breast cancer death was low with minimal differences across FRI scores. NCI comorbidity index-adjusted models and stratified analyses yielded similar patterns. CONCLUSIONS: Risk of non-breast cancer death substantially increases with FRI score, whereas risk of breast cancer death is low regardless of functional status. IMPACT: Older women with functional limitations should be informed that they may not benefit from screening mammography.

2.
Biometrics ; 2021 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-33939839

RESUMO

Screening tests are widely recommended for the early detection of disease among asymptomatic individuals. While detecting disease at an earlier stage has the potential to improve outcomes, screening also has negative consequences, including false positive results which may lead to anxiety, unnecessary diagnostic procedures, and increased healthcare costs. In addition, multiple false positive results could discourage participating in subsequent screening rounds. Screening guidelines typically recommend repeated screening over a period of many years, but little prior research has investigated how often individuals receive multiple false positive test results. Estimating the cumulative risk of multiple false positive results over the course of multiple rounds of screening is challenging due to the presence of censoring and competing risks, which may depend on the false positive risk, screening round, and number of prior false positive results. To address the general challenge of estimating the cumulative risk of multiple false positive test results, we propose a nonhomogeneous multistate model to describe the screening process including competing events. We developed alternative approaches for estimating the cumulative risk of multiple false positive results using this multistate model based on existing estimators for the cumulative risk of a single false positive. We compared the performance of the newly proposed models through simulation studies and illustrate model performance using data on screening mammography from the Breast Cancer Surveillance Consortium. Across most simulation scenarios, the multistate extension of a censoring bias model demonstrated lower bias compared to other approaches. In the context of screening mammography, we found that the cumulative risk of multiple false positive results is high. For instance, based on the censoring bias model, for a high-risk individual, the cumulative probability of at least two false positive mammography results after 10 rounds of annual screening is 40.4.

3.
Radiology ; : 204581, 2021 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-34003059

RESUMO

Background Since 2007, digital mammography and digital breast tomosynthesis (DBT) replaced screen-film mammography. Whether these technologic advances have improved diagnostic performance has, to the knowledge of the authors, not yet been established. Purpose To evaluate the performance and outcomes of surveillance mammography (digital mammography and DBT) performed from 2007 to 2016 in women with a personal history of breast cancer and compare with data from 1996 to 2007 and the performance of digital mammography screening benchmarks. Materials and Methods In this observational cohort study, five Breast Cancer Surveillance Consortium registries provided prospectively collected mammography data linked with tumor registry and pathologic outcomes. This study identified asymptomatic women with American Joint Committee on Cancer anatomic stages 0-III primary breast cancer who underwent surveillance mammography from 2007 to 2016. The primary outcome was a second breast cancer diagnosis within 1 year of mammography. Performance measures included the recall rate, cancer detection rate, interval cancer rate, positive predictive value of biopsy recommendation, sensitivity, and specificity. Results Among 32 331 women who underwent 117 971 surveillance mammographic examinations (112 269 digital mammographic examinations and 5702 DBT examinations), the mean age at initial diagnosis was 59 years ± 12 (standard deviation). Of 1418 second breast cancers diagnosed, 998 were surveillance-detected cancers and 420 were interval cancers. The recall rate was 8.8% (10 365 of 117 971; 95% CI: 8.6%, 9.0%), the cancer detection rate was 8.5 per 1000 examinations (998 of 117 971; 95% CI: 8.0, 9.0), the interval cancer rate was 3.6 per 1000 examinations (420 of 117 971; 95% CI: 3.2, 3.9), the positive predictive value of biopsy recommendation was 31.0% (998 of 3220; 95% CI: 29.4%, 32.7%), the sensitivity was 70.4% (998 of 1418; 95% CI: 67.9%, 72.7%), and the specificity was 98.1% (114 331 of 116 553; 95% CI: 98.0%, 98.2%). Compared with previously published studies, interval cancer rate was comparable with rates from 1996 to 2007 in women with a personal history of breast cancer and was higher than the published digital mammography screening benchmarks. Conclusion In transitioning from screen-film to digital mammography and digital breast tomosynthesis, surveillance mammography performance demonstrated minimal improvement over time and remained inferior to the performance of screening mammography benchmarks. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Moy and Gao in this issue.

4.
PLoS One ; 16(4): e0248643, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33882069

RESUMO

BACKGROUND: Children with central nervous system (CNS) tumors undergo frequent imaging for diagnosis and follow-up, but few studies have characterized longitudinal imaging patterns. We described medical imaging in children before and after malignant CNS tumor diagnosis. PROCEDURE: We conducted a retrospective cohort study of children aged 0-20 years diagnosed with CNS tumors between 1996-2016 at six U.S. integrated healthcare systems and Ontario, Canada. We collected computed topography (CT), magnetic resonance imaging (MRI), radiography, ultrasound, nuclear medicine examinations from 12 months before through 10 years after CNS diagnosis censoring six months before death or a subsequent cancer diagnosis, disenrollment from the health system, age 21 years, or December 31, 2016. We calculated imaging rates per child per month stratified by modality, country, diagnosis age, calendar year, time since diagnosis, and tumor grade. RESULTS: We observed 1,879 children with median four years follow-up post-diagnosis in the U.S. and seven years in Ontario, Canada. During the diagnosis period (±15 days of diagnosis), children averaged 1.10 CTs (95% confidence interval [CI] 1.09-1.13) and 2.14 MRIs (95%CI 2.12-2.16) in the U.S., and 1.67 CTs (95%CI 1.65-1.68) and 1.86 MRIs (95%CI 1.85-1.88) in Ontario. Within one year after diagnosis, 19% of children had ≥5 CTs and 45% had ≥5 MRIs. By nine years after diagnosis, children averaged one MRI and one radiograph per year with little use of other imaging modalities. CONCLUSIONS: MRI and CT are commonly used for CNS tumor diagnosis, whereas MRI is the primary modality used during surveillance of children with CNS tumors.

5.
J Natl Cancer Inst ; 2021 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-33778894

RESUMO

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic led to a near-total cessation of mammography services in the United States in mid-March 2020. It is unclear if screening and diagnostic mammography volumes have recovered to pre-pandemic levels and whether utilization has varied by women's characteristics. METHODS: We collected data on 461,083 screening mammograms and 112,207 diagnostic mammograms conducted during January 2019 through July 2020 at 62 radiology facilities in the Breast Cancer Surveillance Consortium. We compared monthly screening and diagnostic mammography volumes before and during the pandemic, stratified by age, race/ethnicity, breast density, and family history of breast cancer. RESULTS: Screening and diagnostic mammography volumes in April 2020 were 1.1% (95% confidence interval [CI] = 0.5% to 2.4%) and 21.4% (95% CI = 18.7% to 24.4%) of April 2019 pre-pandemic volumes, respectively, but by July 2020 rebounded to 89.7% (95% CI = 79.6% to 101.1%) and 101.6% (95% CI = 93.8% to 110.1%) of July 2019 pre-pandemic volumes, respectively. The year-to-date cumulative volume of screening and diagnostic mammograms performed through July 2020 was 66.2% (95% CI = 60.3% to 72.6%) and 79.9% (95% CI = 75.4% to 84.6%), respectively, of year-to-date volume through July 2019. Screening mammography rebound was similar across age groups and by family history of breast cancer. Monthly screening mammography volume in July 2020 for Black, White, Hispanic, and Asian women reached 96.7% (95% CI = 88.1% to 106.1%), 92.9% (95% CI = 82.9% to 104.0%), 72.7% (95% CI = 56.5% to 93.6%), and 51.3% (95% CI = 39.7% to 66.2%) of July 2019 pre-pandemic volume, respectively. CONCLUSION: Despite a strong overall rebound in mammography volume by July 2020, the rebound lagged among Asian and Hispanic women and a substantial cumulative deficit in missed mammograms accumulated, which may have important health consequences.

6.
JAMA Netw Open ; 4(3): e211974, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33764423

RESUMO

Importance: Breast cancer screening, surveillance, and diagnostic imaging services were profoundly limited during the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. Objective: To develop a risk-based strategy for triaging mammograms during periods of decreased capacity. Design, Setting, and Participants: This population-based cohort study used data collected prospectively from mammography examinations performed in 2014 to 2019 at 92 radiology facilities in the Breast Cancer Surveillance Consortium. Participants included individuals undergoing mammography. Data were analyzed from August 10 to November 3, 2020. Exposures: Clinical indication for screening, breast symptoms, personal history of breast cancer, age, time since last mammogram/screening interval, family history of breast cancer, breast density, and history of high-risk breast lesion. Main Outcomes and Measures: Combinations of clinical indication, clinical history, and breast cancer risk factors that subdivided mammograms into risk groups according to their cancer detection rate were identified using classification and regression trees. Results: The cohort included 898 415 individuals contributing 1 878 924 mammograms (mean [SD] age at mammogram, 58.6 [11.2] years) interpreted by 448 radiologists, with 1 722 820 mammograms in individuals without a personal history of breast cancer and 156 104 mammograms in individuals with a history of breast cancer. Most individuals were aged 50 to 69 years at imaging (1 113 174 mammograms [59.2%]), and 204 305 (11.2%) were Black, 206 087 (11.3%) were Asian or Pacific Islander, 126 677 (7.0%) were Hispanic or Latina, and 40 021 (2.2%) were another race/ethnicity or mixed race/ethnicity. Cancer detection rates varied widely based on clinical indication, breast symptoms, personal history of breast cancer, and age. The 12% of mammograms with very high (89.6 [95% CI, 82.3-97.5] to 122.3 [95% CI, 108.1-138.0] cancers detected per 1000 mammograms) or high (36.1 [95% CI, 33.1-39.3] to 47.5 [95% CI, 42.4-53.3] cancers detected per 1000 mammograms) cancer detection rates accounted for 55% of all detected cancers and included mammograms to evaluate an abnormal mammogram or breast lump in individuals of all ages regardless of breast cancer history, to evaluate breast symptoms other than lump in individuals with a breast cancer history or without a history but aged 60 years or older, and for short-interval follow-up in individuals aged 60 years or older without a breast cancer history. The 44.2% of mammograms with very low cancer detection rates accounted for 13.1% of detected cancers and included annual screening mammograms in individuals aged 50 to 69 years (3.8 [95% CI, 3.5-4.1] cancers detected per 1000 mammograms) and all screening mammograms in individuals younger than 50 years regardless of screening interval (2.8 [95% CI, 2.6-3.1] cancers detected per 1000 mammograms). Conclusions and Relevance: In this population-based cohort study, clinical indication and individual risk factors were associated with cancer detection and may be useful for prioritizing mammography in times and settings of decreased capacity.


Assuntos
Neoplasias da Mama/diagnóstico , COVID-19 , Alocação de Recursos para a Atenção à Saúde/métodos , Mamografia , Programas de Rastreamento/métodos , Pandemias , Triagem/métodos , Idoso , Mama/diagnóstico por imagem , Mama/patologia , COVID-19/prevenção & controle , Estudos de Coortes , Detecção Precoce de Câncer , Feminino , Humanos , Anamnese , Pessoa de Meia-Idade , Exame Físico , Radiologia , Fatores de Risco , SARS-CoV-2
7.
J Pediatr ; 2021 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-33684394

RESUMO

OBJECTIVE: To assess leukemia risks among children with Down syndrome in a large, contemporary cohort. STUDY DESIGN: Retrospective cohort study including 3 905 399 children born 1996-2016 in 7 US healthcare systems or Ontario, Canada, and followed from birth to cancer diagnosis, death, age 15 years, disenrollment, or December 30, 2016. Down syndrome was identified using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. Cancer diagnoses were identified through linkages to tumor registries. Incidence and hazard ratios (HRs) of leukemia were estimated for children with Down syndrome and other children adjusting for health system, child's age at diagnosis, birth year, and sex. RESULTS: Leukemia was diagnosed in 124 of 4401 children with Down syndrome and 1941 of 3 900 998 other children. In children with Down syndrome, the cumulative incidence of acute myeloid leukemia (AML) was 1405/100 000 (95% CI 1076-1806) at age 4 years and unchanged at age 14 years. The cumulative incidence of acute lymphoid leukemia in children with Down syndrome was 1059/100 000 (95% CI 755-1451) at age 4 and 1714/100 000 (95% CI 1264-2276) at age 14 years. Children with Down syndrome had a greater risk of AML before age 5 years than other children (HR 399, 95% CI 281-566). Largest HRs were for megakaryoblastic leukemia before age 5 years (HR 1500, 95% CI 555-4070). Children with Down syndrome had a greater risk of acute lymphoid leukemia than other children regardless of age (<5 years: HR 28, 95% CI 20-40, ≥5 years HR 21, 95% CI 12-38). CONCLUSIONS: Down syndrome remains a strong risk factor for childhood leukemia, and associations with AML are stronger than previously reported.

9.
JAMA Netw Open ; 4(2): e2037546, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33606032

RESUMO

Importance: Digital breast tomosynthesis (DBT) has reduced recall and increased cancer detection compared with digital mammography (DM), depending on women's age and breast density. Whether DBT screening access and use are equitable across groups of women based on race/ethnicity and socioeconomic characteristics is uncertain. Objective: To determine women's access to and use of DBT screening based on race/ethnicity, educational attainment, and income. Design, Setting, and Participants: This cross-sectional study included 92 geographically diverse imaging facilities across 5 US states, at which a total of 2 313 118 screening examinations were performed among women aged 40 to 89 years from January 1, 2011, to December 31, 2017. Data were analyzed from June 13, 2019, to August 18, 2020. Exposures: Women's race/ethnicity, educational level, and community-level household income. Main Outcomes and Measures: Access to DBT (on-site access) at time of screening by examination year and actual use of DBT vs DM screening by years since facility-level DBT adoption (≤5 years). Results: Among the 2 313 118 screening examinations included in the analysis, the proportion of women who had DBT access at the time of their screening appointment increased from 11 558 of 354 107 (3.3%) in 2011 to 194 842 of 235 972 (82.6%) in 2017. In 2012, compared with White women, Black (relative risk [RR], 0.05; 95% CI, 0.03-0.11), Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly less DBT access, and women with less than a high school education had lower DBT access compared with college graduates (RR, 0.18; 95% CI, 0.10-0.32). Among women attending facilities with both DM and DBT available at the time of screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] to 0.98 [95% CI, 0.97-0.99]); women with lower educational level experienced lower DBT use (RRs, 0.79 [95% CI, 0.74-0.84] to 0.88 [95% CI, 0.85-0.91] for non-high school graduates and 0.90 [95% CI, 0.89-0.92] to 0.96 [95% CI, 0.93-0.99] for high school graduates vs college graduates); and women within the lowest income quartile experienced lower DBT use vs women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]) regardless of the number of years after facility-level DBT adoption. Conclusions and Relevance: In this cross-sectional study, women of minority race/ethnicity and lower socioeconomic status experienced lower DBT access during the early adoption period and persistently lower DBT use when available over time. Future efforts should address racial/ethnic, educational, and financial barriers to DBT screening.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Escolaridade , Grupos Étnicos/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Renda/estatística & dados numéricos , Mamografia/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Americanos Asiáticos/estatística & dados numéricos , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hispano-Americanos/estatística & dados numéricos , Humanos , Mamografia/métodos , Pessoa de Meia-Idade , Classe Social , Estados Unidos
10.
J Natl Cancer Inst ; 2021 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-33515225

RESUMO

BACKGROUND: A paucity of research addresses breast cancer screening strategies for women at lower-than-average breast cancer risk. The aim of this study was to examine screening harms and benefits among women aged 50-74 years at lower-than-average breast cancer risk by breast density. METHODS: Three well-established, validated Cancer Intervention and Surveillance Network models were used to estimate the lifetime benefits and harms of different screening scenarios, varying by screening interval (biennial, triennial). Breast cancer deaths averted, life-years and quality-adjusted life-years gained, false-positives, benign biopsies, and overdiagnosis were assessed by relative risk (RR) level (0.6, 0.7, 0.85, 1 [average risk]) and breast density category, for US women born in 1970. RESULTS: Screening benefits decreased proportionally with decreasing risk and with lower breast density. False-positives, unnecessary biopsies, and the percentage overdiagnosis also varied substantially by breast density category; false-positives and unnecessary biopsies were highest in the heterogeneously dense category. For women with fatty or scattered fibroglandular breast density and a relative risk of no more than 0.85, the additional deaths averted and life-years gained were small with biennial vs triennial screening. For these groups, undergoing 4 additional screens (screening biennially [13 screens] vs triennially [9 screens]) averted no more than 1 additional breast cancer death and gained no more than 16 life-years and no more than 10 quality-adjusted life-years per 1000 women but resulted in up to 232 more false-positives per 1000 women. CONCLUSION: Triennial screening from age 50 to 74 years may be a reasonable screening strategy for women with lower-than-average breast cancer risk and fatty or scattered fibroglandular breast density.

11.
JAMA Netw Open ; 3(11): e2026930, 2020 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-33216141

RESUMO

Importance: In response to calls to reduce unnecessary diagnostic testing with computed tomographic pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), there have been growing efforts to create and implement decision rules for PE testing. It is unclear if the use of advanced imaging tests for PE has diminished over time. Objective: To assess the use of advanced imaging tests, including chest computed tomography (CT) (ie, all chest CT except for CTPA), CTPA, and ventilation-perfusion (V/Q) scan, for PE from 2004 to 2016. Design, Setting, and Participants: Cohort study of adults by age group (18-64 years and ≥65 years) enrolled in 7 US integrated and mixed-model health care systems. Joinpoint regression analysis was used to identify years with statistically significant changes in imaging rates and to calculate average annual percentage change (growth) from 2004 to 2007, 2008 to 2011, and 2012 to 2016. Analyses were conducted between June 11, 2019, and March 18, 2020. Main Outcomes and Measures: Rates of chest CT, CTPA, and V/Q scan by year and age, as well as annual change in rates over time. Results: Overall, 3.6 to 4.8 million enrollees were included each year of the study, for a total of 52 343 517 person-years of follow-up data. Adults aged 18 to 64 years accounted for 42 223 712 person-years (80.7%) and those 65 years or older accounted for 10 119 805 person-years (19.3%). Female enrollees accounted for 27 712 571 person-years (52.9%). From 2004 and 2016, chest CT use increased by 66.3% (average annual growth, 4.4% per year), CTPA use increased by 450.0% (average annual growth, 16.3% per year), and V/Q scan use decreased by 47.1% (decreasing by 4.9% per year). The use of CTPA increased most rapidly from 2004 to 2006 (44.6% in those aged 18-64 years and 43.9% in those ≥65 years), with ongoing rapid growth from 2006 to 2010 (annual growth, 19.8% in those aged 18-64 years and 18.3% in those ≥65 years) and persistent but slower growth in the most recent years (annual growth, 4.3% in those aged 18-64 years and 3.0% in those ≥65 years from 2010 to 2016). The use of V/Q scanning decreased steadily since 2004. Conclusions and Relevance: From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years. Efforts to combat overuse have not been completely successful as reflected by ongoing growth, rather than decline, of chest CT use. Whether the observed imaging use was appropriate or was associated with improved patient outcomes is unknown.

12.
J Am Coll Radiol ; 2020 Nov 16.
Artigo em Inglês | MEDLINE | ID: mdl-33212069

RESUMO

PURPOSE: The aim of this study was to examine radiologists' beliefs about existing guidelines for pulmonary nodule evaluation. METHODS: A self-administered survey was developed to ascertain awareness of, agreement with, and adherence to published guidelines, including those from the Fleischner Society and the Lung CT Screening Reporting and Data System (Lung-RADS™). Surveys were distributed to 514 radiologists at 13 health care systems that are participating in a large, pragmatic trial of pulmonary nodule evaluation. Prespecified comparisons were made among groups defined by type of health system, years of experience, reader volume, and study arm. RESULTS: The response rate was 26.3%. Respondents were most familiar with guidelines from Fleischner (94%) and Lung-RADS (71%). For both incidental and screening-detected nodules, self-reported adherence to preferred guidelines was very high (97% and 94%, respectively), and most respondents believed that the benefits of adherence outweigh the harms (81% and 74%, respectively). Underlying evidence was thought to be high in quality by 68% of respondents for screening-detected nodules and 41% for incidental nodules. Approximately 70% of respondents believed that the frequency of recommended follow-up was "just right" for both guidelines. Radiologists who practice in nonintegrated health care systems were more likely to believe that the evidence was high in quality (79.5% vs 57.1%) and that the benefits of adherence outweigh the harms (85.1% vs 67.5%). Low-volume readers had lower awareness and self-reported adherence than higher volume readers. CONCLUSIONS: Radiologists reported high levels of familiarity and agreement with and adherence to guidelines for pulmonary nodule evaluation, but many overestimated the quality of evidence in support of the recommendations.

13.
J Natl Cancer Inst ; 2020 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-33169794

RESUMO

BACKGROUND: Advanced breast cancer is an outcome used to evaluate screening effectiveness. The advanced cancer definition resulting in the best discrimination of breast cancer death has not been studied in a breast imaging population. METHODS: 52,496 women aged 40-79 years participating in the Breast Cancer Surveillance Consortium diagnosed with invasive cancer were staged using the eighth edition of American Joint Committee on Cancer (AJCC) anatomic and prognostic pathologic systems and Tomosynthesis Mammographic Imaging Screening Trial (TMIST) tumor categories. We calculated the area under the receiver operating characteristic curve (AUC) for predicting 5-year breast cancer death and the sensitivity and specificity for predicting 5-year breast cancer death for three advanced cancer classifications; anatomic stage IIB or higher, prognostic pathologic stage IIA or higher, and TMIST advanced cancer. RESULTS: The AUCs for predicting 5-year breast cancer death for AJCC anatomic stage, AJCC prognostic pathologic stage, and TMIST tumor categories were 0.826 (95% confidence interval [CI]=0.817, 0.835), 0.856 (95%CI = 0.846, 0.866), and 0.789 (95%CI = 0.780, 0.797), respectively. AJCC prognostic pathologic stage had statistically significantly better discrimination than AJCC anatomic stage (difference = 0.030, bootstrap 95%CI = 0.024, 0.037) and TMIST tumor categories (difference = 0.067, bootstrap 95%CI = 0.059, 0.075). The sensitivity and specificity for predicting 5-year breast cancer death for AJCC anatomic stage IIB or higher, AJCC prognostic pathologic stage IIA or higher, and TMIST advanced cancer were (72.6%, 76.7%, 96.1%) and (78.9%, 81.6%, 41.1%), respectively. CONCLUSION: Defining advanced cancer as AJCC prognostic pathologic stage IIA or higher most accurately predicts breast cancer death. Use of this definition by investigators will facilitate comparing breast cancer screening effectiveness studies.

14.
Artigo em Inglês | MEDLINE | ID: mdl-33098534

RESUMO

PURPOSE: Women with a first-degree family history of breast cancer (FHBC) are sometimes advised to initiate screening mammography when they are 10 years younger than the age at which their youngest relative was diagnosed, despite a lack of unambiguous evidence that this is an effective strategy. It is unknown how often this results in women initiating screening earlier (< 40 years) than screening guidelines recommend for average-risk women. METHODS: We examined screening initiation age by FHBC and age at diagnosis of the youngest relative using data collected by the Breast Cancer Surveillance Consortium on 74,838 first screening mammograms performed between 1996 and 2016. RESULTS: Of the 74,838 women included in the study, nearly 9% reported a FHBC. Approximately 16.8% of women who initiated mammography before 40 years reported a FHBC. More women with a FHBC than without initiated screening < 40 years (48% vs. 23%, respectively). Among women with a FHBC who initiated screening < 40 years, 65% were 10 years younger than the age at which their relative was diagnosed. CONCLUSION: Women with a first-degree relative diagnosed with breast cancer were more likely to start screening before 40 years than women reporting no FHBC, especially if their relative was diagnosed before 50 years.

15.
JAMA Netw Open ; 3(7): e2011792, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32721031

RESUMO

Importance: Digital mammography (DM) and digital breast tomosynthesis (DBT) are used for routine breast cancer screening. There is minimal evidence on performance outcomes by age, screening round, and breast density in community practice. Objective: To compare DM vs DBT performance by age, baseline vs subsequent screening round, and breast density category. Design, Setting, and Participants: This comparative effectiveness study assessed 1 584 079 screening examinations of women aged 40 to 79 years without prior history of breast cancer, mastectomy, or breast augmentation undergoing screening mammography at 46 participating Breast Cancer Surveillance Consortium facilities from January 2010 to April 2018. Exposures: Age, Breast Imaging Reporting and Data System breast density category, screening round, and modality. Main Outcomes and Measures: Absolute rates and relative risks (RRs) of screening recall and cancer detection. Results: Of 1 273 492 DM and 310 587 DBT examinations analyzed, 1 028 891 examinations (65.0%) were of white non-Hispanic women; 399 952 women (25.2%) were younger than 50 years; and 671 136 women (42.4%) had heterogeneously dense or extremely dense breasts. Adjusted differences in DM vs DBT performance were largest on baseline examinations: for example, per 1000 baseline examinations in women ages 50 to 59, recall rates decreased from 241 examinations for DM to 204 examinations for DBT (RR, 0.84; 95% CI, 0.73-0.98), and cancer detection rates increased from 5.9 with DM to 8.8 with DBT (RR, 1.50; 95% CI, 1.10-2.08). On subsequent examinations, women aged 40 to 79 years with heterogeneously dense breasts had improved recall rates and improved cancer detection with DBT. For example, per 1000 examinations in women aged 50 to 59 years, the number of recall examinations decreased from 102 with DM to 93 with DBT (RR, 0.91; 95% CI, 0.84-0.98), and cancer detection increased from 3.7 with DM to 5.3 with DBT (RR, 1.42; 95% CI, 1.23-1.64). Women aged 50 to 79 years with scattered fibroglandular density also had improved recall and cancer detection rates with DBT. Women aged 40 to 49 years with scattered fibroglandular density and women aged 50 to 79 years with almost entirely fatty breasts benefited from improved recall rates without change in cancer detection rates. No improvements in recall or cancer detection rates were observed in women with extremely dense breasts on subsequent examinations for any age group. Conclusions and Relevance: This study found that improvements in recall and cancer detection rates with DBT were greatest on baseline mammograms. On subsequent screening mammograms, the benefits of DBT varied by age and breast density. Women with extremely dense breasts did not benefit from improved recall or cancer detection with DBT on subsequent screening rounds.

16.
Cancer Epidemiol Biomarkers Prev ; 29(10): 2048-2056, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32727722

RESUMO

BACKGROUND: Overweight/obesity and dense breasts are strong breast cancer risk factors whose prevalences vary by race/ethnicity. The breast cancer population attributable risk proportions (PARP) explained by these factors across racial/ethnic groups are unknown. METHODS: We analyzed data collected from 3,786,802 mammography examinations (1,071,653 women) in the Breast Cancer Surveillance Consortium, associated with 21,253 invasive breast cancers during a median of 5.2 years follow-up. HRs for body mass index (BMI) and breast density, adjusted for age and registry were estimated using separate Cox regression models by race/ethnicity (White, Black, Hispanic, Asian) and menopausal status. HRs were combined with observed risk-factor proportions to calculate PARPs for shifting overweight/obese to normal BMI and shifting heterogeneously/extremely dense to scattered fibroglandular densities. RESULTS: The prevalences and HRs for overweight/obesity and heterogeneously/extremely dense breasts varied across races/ethnicities and menopausal status. BMI PARPs were larger for postmenopausal versus premenopausal women (12.0%-28.3% vs. 1.0%-9.9%) and nearly double among postmenopausal Black women (28.3%) than other races/ethnicities (12.0%-15.4%). Breast density PARPs were larger for premenopausal versus postmenopausal women (23.9%-35.0% vs. 13.0%-16.7%) and lower among premenopausal Black women (23.9%) than other races/ethnicities (30.4%-35.0%). Postmenopausal density PARPs were similar across races/ethnicities (13.0%-16.7%). CONCLUSIONS: Overweight/obesity and dense breasts account for large proportions of breast cancers in White, Black, Hispanic, and Asian women despite large differences in risk-factor distributions. IMPACT: Risk prediction models should consider how race/ethnicity interacts with BMI and breast density. Efforts to reduce BMI could have a large impact on breast cancer risk reduction, particularly among postmenopausal Black women.

17.
Ann Intern Med ; 173(5): 331-341, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32628531

RESUMO

BACKGROUND: Surveillance with annual mammography and breast magnetic resonance imaging (MRI) is recommended for female survivors of childhood cancer treated with chest radiation, yet benefits, harms, and costs are uncertain. OBJECTIVE: To compare the benefits, harms, and cost-effectiveness of breast cancer screening strategies in childhood cancer survivors. DESIGN: Collaborative simulation modeling using 2 Cancer Intervention and Surveillance Modeling Network breast cancer models. DATA SOURCES: Childhood Cancer Survivor Study and published data. TARGET POPULATION: Women aged 20 years with a history of chest radiotherapy. TIME HORIZON: Lifetime. PERSPECTIVE: Payer. INTERVENTION: Annual MRI with or without mammography, starting at age 25, 30, or 35 years. OUTCOME MEASURES: Breast cancer deaths averted, false-positive screening results, benign biopsy results, and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS: Lifetime breast cancer mortality risk without screening was 10% to 11% across models. Compared with no screening, starting at age 25 years, annual mammography with MRI averted the most deaths (56% to 71%) and annual MRI (without mammography) averted 56% to 62%. Both strategies had the most screening tests, false-positive screening results, and benign biopsy results. For an ICER threshold of less than $100 000 per quality-adjusted life-year gained, screening beginning at age 30 years was preferred. RESULTS OF SENSITIVITY ANALYSIS: Assuming lower screening performance, the benefit of adding mammography to MRI increased in both models, although the conclusions about preferred starting age remained unchanged. LIMITATION: Elevated breast cancer risk was based on survivors diagnosed with childhood cancer between 1970 and 1986. CONCLUSION: Early initiation (at ages 25 to 30 years) of annual breast cancer screening with MRI, with or without mammography, might reduce breast cancer mortality by half or more in survivors of childhood cancer. PRIMARY FUNDING SOURCE: American Cancer Society and National Institutes of Health.

18.
Cancer ; 126(14): 3289-3296, 2020 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-32374471

RESUMO

BACKGROUND: Established mammography screening performance metrics use the initial screening mammography assessment because they were developed for radiologist performance auditing, yet these metrics are frequently used to inform health policy and screening decision making. The authors have developed new performance metrics based on the final assessment that consider the entire screening episode, including diagnostic workup. METHODS: The authors used data from 2,512,577 screening episodes during 2005-2017 at 146 facilities in the United States participating in the Breast Cancer Surveillance Consortium. Screening performance metrics based on the final assessment of the screening episode were compared with conventional metrics defined with the initial assessment. Results were also stratified by breast density and breast cancer risk. RESULTS: The cancer detection rates were similar for the final assessment (4.1 per 1000; 95% confidence interval [CI], 3.8-4.3 per 1000) and the initial assessment (4.1 per 1000; 95% CI, 3.9-4.3 per 1000). The interval cancer rate was 12% higher when it was based on the final assessment (0.77 per 1000; 95% CI, 0.71-0.83 per 1000) versus the initial assessment (0.69 per 1000; 95% CI, 0.64-0.74 per 1000), and this resulted in a modest difference in sensitivity (84.1% [95% CI, 83.0%-85.1%] vs 85.7% [95% CI, 84.8%-86.6%], respectively). Absolute differences in the interval cancer rate between final and initial assessments increased with breast density and breast cancer risk (eg, a difference of 0.29 per 1000 for women with extremely dense breasts and a 5-year risk >2.49%). CONCLUSIONS: Established screening performance metrics underestimate the interval cancer rate of a mammography screening episode, particularly for women with dense breasts or an elevated breast cancer risk. Women, clinicians, policymakers, and researchers should use final-assessment performance metrics to support informed screening decisions.

19.
JAMA Intern Med ; 180(5): 666-675, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32227142

RESUMO

Importance: Computed tomography (CT) radiation doses vary across institutions and are often higher than needed. Objective: To assess the effectiveness of 2 interventions to reduce radiation doses in patients undergoing CT. Design, Setting, and Participants: This randomized clinical trial included 864 080 adults older than 18 years who underwent CT of the abdomen, chest, combined abdomen and chest, or head at 100 facilities in 6 countries from November 1, 2015, to September 21, 2017. Data analysis was performed from October 4, 2017, to December 14, 2018. Interventions: Imaging facilities received audit feedback alone comparing radiation-dose metrics with those of other facilities followed by the multicomponent intervention, including audit feedback with targeted suggestions, a 7-week quality improvement collaborative, and best-practice sharing. Facilities were randomly allocated to the time crossing from usual care to the intervention. Main Outcomes and Measures: Primary outcomes were the proportion of high-dose CT scans and mean effective dose at the facility level. Secondary outcomes were organ doses. Outcomes after interventions were compared with those before interventions using hierarchical generalized linear models adjusting for temporal trends and patient characteristics. Results: Across 100 facilities, 864 080 adults underwent 1 156 657 CT scans. The multicomponent intervention significantly reduced proportions of high-dose CT scans, measured using effective dose. Absolute changes in proportions of high-dose scans were 1.1% to 7.9%, with percentage reductions in the proportion of high-dose scans of 4% to 30% (abdomen: odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P < .001; chest: OR, 0.92; 95% CI, 0.86-0.99; P = .03; combined abdomen and chest: OR, 0.49; 95% CI, 0.41-0.59; P < .001; and head: OR, 0.71; 95% CI, 0.66-0.76; P < .001). Reductions in the proportions of high-dose scans were greater when measured using organ doses. The absolute reduction in the proportion of high-dose scans was 6.0% to 17.2%, reflecting 23% to 58% reductions in the proportions of high-dose scans across anatomical areas. Mean effective doses were significantly reduced after multicomponent intervention for abdomen (6% reduction, P < .001), chest (4%, P < .001), and chest and abdomen (14%, P < .001) CT scans. Larger reductions in mean organ doses were 8% to 43% across anatomical areas. Audit feedback alone reduced the proportions of high-dose scans and mean dose, but reductions in observed dose were smaller. Radiologist's satisfaction with CT image quality was unchanged and high during all periods. Conclusions and Relevance: For imaging facilities, detailed feedback on CT radiation dose combined with actionable suggestions and quality improvement education significantly reduced doses, particularly organ doses. Effects of audit feedback alone were modest. Trial Registration: ClinicalTrials.gov Identifier: NCT03000751.

20.
JAMA Netw Open ; 3(3): e201759, 2020 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-32227180

RESUMO

Importance: Many US radiologists have screening mammography recall rates above the expert-recommended threshold of 12%. The influence of digital breast tomosynthesis (DBT) on the distribution of radiologist recall rates is uncertain. Objective: To evaluate radiologists' recall and cancer detection rates before and after beginning interpretation of DBT examinations. Design, Setting, and Participants: This cohort study included 198 radiologists from 104 radiology facilities in the Breast Cancer Surveillance Consortium who interpreted 251 384 DBT and 2 000 681 digital mammography (DM) screening examinations from 2009 to 2017, including 126 radiologists (63.6%) who interpreted DBT examinations during the study period and 72 (36.4%) who exclusively interpreted DM examinations (to adjust for secular trends). Data were analyzed from April 2018 to July 2019. Exposures: Digital breast tomosynthesis and DM screening examinations. Main Outcomes and Measures: Recall rate and cancer detection rate. Results: A total of 198 radiologists interpreted 2 252 065 DM and DBT examinations (2 000 681 [88.8%] DM examinations; 251 384 [11.2%] DBT examinations; 710 934 patients [31.6%] aged 50-59 years; 1 448 981 [64.3%] non-Hispanic white). Among the 126 radiologists (63.6%) who interpreted DBT examinations, 83 (65.9%) had unadjusted DM recall rates of no more than 12% before using DBT, with a median (interquartile range) recall rate of 10.0% (7.5%-13.0%). On DBT examinations, 96 (76.2%) had an unadjusted recall rate of no more than 12%, with a median (interquartile range) recall rate of 8.8% (6.3%-11.3%). A secular trend in recall rate was observed, with the multivariable-adjusted risk of recall on screening examinations declining by 1.2% (95% CI, 0.9%-1.5%) per year. After adjusting for examination characteristics and secular trends, recall rates were 15% lower on DBT examinations compared with DM examinations interpreted before DBT use (relative risk, 0.85; 95% CI, 0.83-0.87). Adjusted recall rates were significantly lower on DBT examinations compared with DM examinations interpreted before DBT use for 45 radiologists (35.7%) and significantly higher for 18 (14.3%); 63 (50.0%) had no statistically significant change. The unadjusted cancer detection rate on DBT was 5.3 per 1000 examinations (95% CI, 5.0-5.7 per 1000 examinations) compared with 4.7 per 1000 examinations (95% CI, 4.6-4.8 per 1000 examinations) on DM examinations interpreted before DM use (multivariable-adjusted risk ratio, 1.21; 95% CI, 1.11-1.33). Conclusions and Relevance: In this study, DBT was associated with an overall decrease in recall rate and an increase in cancer detection rate. However, our results indicated that there is wide variability among radiologists, including a subset of radiologists who experienced increased recall rates on DBT examinations. Radiology practices should audit radiologist DBT screening performance and consider additional DBT training for radiologists whose performance does not improve as expected.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Mamografia , Radiologistas , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/epidemiologia , Estudos de Coortes , Feminino , Humanos , Mamografia/métodos , Mamografia/estatística & dados numéricos , Pessoa de Meia-Idade , Radiologistas/normas , Radiologistas/estatística & dados numéricos , Estados Unidos
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