Impact of an Information Technology-Enabled Quality Improvement Initiative on Timeliness of Patient Contact and Scheduling of Screening Mammography Recall.

OBJECTIVE. The purpose of this study was to evaluate the impact of an information technology-enabled quality improvement initiative on timeliness of patient contact and scheduling of screening mammography recall. MATERIALS AND METHODS. The study was conducted in a screening practice (two ambulatory centers, A and B; two hospitals, C and D) that uses offline batch results (A, B, C) and same-day results (D) with on-site (A, C, D) or off-site (B) coordinators scheduling recalls. Before the intervention, radiologists at sites A, B, and C conveyed recalls via paper lists to coordinators after batch interpretation. At site D, coordinators received recall lists several times a day. In March 2017 an electronic alert system was implemented to notify coordinators of recall at report signing with required closed-loop acknowledgment once recall was scheduled. Mean time (hours, excluding weekends) to schedule diagnostic evaluation was compared for 4-month periods before and after intervention by two-tailed t test and statistical process control analyses. RESULTS. Recall rates were 9.5% (1356/14,315) before and 8.9% (1432/16,034) after the intervention (p = 0.10). Mean time to schedule screening decreased after the intervention as follows: site A from 86 to 65 hours (-24.4%, p = 0.01); site B, 116 to 70 hours (-39.7%, p < 0.0001); site C, 98 to 65 hours (-33.7%, p = 0.002); and site D, 49 to 42 hours (-14.3%, p = 0.21). Statistical process control analysis showed significant sustained improvements at sites A, B, and C in mean time to patient contact and scheduling of diagnostic evaluation. CONCLUSION. An information technology-enabled quality improvement initiative to notify coordinators of screening recalls in real time with required patient contact and scheduling acknowledgment reduced time to diagnostic scheduling in a multisite practice. The greatest impact was found at the site with off-site coordinators, the least at the site performing same-day interpretation.

Distinguishing papillary endothelial hyperplasia and angiosarcoma on core needle biopsy of the breast: The importance of clinical and radiologic correlation.

Papillary endothelial hyperplasia (PEH) is a rare non-neoplastic exuberant organizing hematoma that can closely mimic angiosarcoma due to a resemblance to malignant anastomosing blood vessels. It could be particularly difficult to distinguish PEH from angiosarcoma in breast core needle biopsies. We identified all cases of these lesions diagnosed on core needle biopsy in order to identify clinical, radiologic, and pathologic features that could prove helpful to arrive at the correct diagnosis. Four cases of PEH and 4 cases of angiosarcoma were identified. The mean age at diagnosis was 62 for PEH and 33 for primary angiosarcoma. All cases of PEH formed small masses with circumscribed or lobulated margins by imaging (mean size 0.9 cm). In 3 cases, the masses were difficult or impossible to identify after the biopsy. Angiosarcomas presented as larger masses with ill-defined margins (mean size 2.8 cm) that were unchanged in size after biopsy. PEH was surrounded by adipose tissue, whereas angiosarcoma invaded into fibrous stroma and involved lobules. The pseudopapillary structures of PEH were composed mainly of collagen, and thus, additional histologic stains for fibrin were not helpful for diagnosis. The 4 patients with PEH received no further treatment and are alive and disease-free at 2-11 years of follow-up. In contrast, the patients with angiosarcoma underwent mastectomy and chemotherapy or radiation therapy. Two of the patients with angiosarcoma died 3 years after diagnosis and the other 2 patients are alive without disease at 5 and 6 years. Therefore, distinguishing PEH and angiosarcoma is essential for appropriate management. This is the first series to compare these lesions on core needle biopsy and the first to note important clinical, imaging, and histologic differences that aid in making a diagnosis of PEH with confidence on breast core needle biopsy.

Imaging and Histopathologic Features of BI-RADS 3 Lesions Upgraded during Imaging Surveillance.

To evaluate imaging and histopathologic differences between screen-detected benign and malignant upgraded lesions initially assessed as BI-RADS 3 at diagnostic evaluation. An IRB approved retrospective review of the mammography data base from January 1, 2004 to December 31, 2008 identified 1,188 (1.07%) of 110,776 screening examinations assessed as BI-RADS 3 following diagnostic evaluation at our academic center (staffed by breast specialists) or our outpatient center (staffed by general radiologists), 1,017 with at least 24 months follow-up or biopsy. Sixty (5.9%) BI-RADS 3 lesions were upgraded to BI-RADS 4 or 5 during imaging surveillance (study population). Prospective reports, patient demographics, and clinical outcomes were abstracted from the longitudinal medical record. Mean patient age was 54.1 years (range 35-85). Lesions consisted of 7 masses, 12 focal asymmetries and 41 calcifications. Fifteen (25%) of 60 lesions upgraded from initial BI-RADS 3 assessment were malignant (1.47% of total; 15/1,017 BI-RADS 3 studies). Malignancy rates by upgraded lesion type showed no significant difference: Thirty-three (73.3%) of 45 benign upgraded lesions were calcifications compared to 8 (53.3%) of 15 malignant upgraded lesions (p = 0.202). Twelve (26.7%) of 45 benign upgraded lesions were masses or focal asymmetries, compared to 7 (46.7%) of 15 upgraded malignant lesions (p = 0.202). Six (85.7%) of 7 malignant upgraded masses/focal asymmetries had no US correlate at initial BI-RADS 3 assessment compared to 7 (58.3%) of 12 benign upgraded masses/focal asymmetries (p = 0.33). Breast-imaging specialists interpreted 21 studies, 3 (14.3%) malignant; general radiologists interpreted 39 studies, 12 (30.8%) malignant (p = 0.218). There was no significant difference in malignancy rate among different types of upgraded mammographic lesions, nor depending on subspecialty interpretation versus nonsubspecialist interpretation. Although calcifications made up a majority of upgraded lesions, most were benign, suggesting that decreased surveillance of calcifications may be appropriate.

Assessment and Management of Challenging BI-RADS Category 3 Mammographic Lesions.

Breast Imaging Reporting and Data System (BI-RADS) category 3 lesions are probably benign by definition and are recommended for short-interval follow-up after a diagnostic workup has been completed. Although the original lexicon-derived BI-RADS category 3 definition applied to lesions without prior imaging studies (when stability could not be determined), in clinical practice, many lesions with prior images may be assigned to BI-RADS category 3. Although the BI-RADS fifth edition specifically delineates lesions that are appropriate for categorization as probably benign, it also specifies that the interpreting radiologist may use his or her discretion and experience to justify a "watchful waiting" approach for lesions that do not meet established criteria. Examples of such lesions include evolving masses or calcifications suggestive of prior trauma and instances when stability cannot be ascertained because of image quality. Although interval change is an important feature of malignancy, many benign lesions also change over time; thus, use of prior imaging studies and ongoing imaging surveillance to demonstrate the evolution of a probably benign lesion is justified. Some examples of common pitfalls associated with inappropriate BI-RADS category 3 assessment include failure to use proper BI-RADS descriptors, failure to perform a complete diagnostic workup, and overreliance on negative ultrasonographic findings. When appropriately used, short-interval follow-up saves many patients from undergoing biopsy of benign lesions, without decreasing the rate of cancer detection. (©)RSNA, 2016.

Patient compliance and diagnostic yield of 18-month unilateral follow-up in surveillance of probably benign mammographic lesions.

OBJECTIVE: The purpose of this study is to determine the patient compliance with and diagnostic yield of 18-month unilateral mammography in surveillance of probably benign (BI-RADS category 3) lesions. MATERIALS AND METHODS: This retrospective study identified lesions prospectively classified BI-RADS 3 in asymptomatic women from January 1, 2004, to December 31, 2008. Surveillance protocol for BI-RADS 3 lesions included 6-month (unilateral), 12-month (bilateral), 18-month (unilateral), and 24-month (bilateral) imaging, with subsequent annual screening. Demographics, surveillance data, BI-RADS upgrades and downgrades, and biopsy results were abstracted from the longitudinal medical record. RESULTS: One thousand one hundred eighty-eight lesions in 1077 patients (mean age, 51.5 years; age range, 26-89 years) had BI-RADS 3 assessment, representing 1.07% of all screening examinations. The compliance rates for follow-up at 6, 12, 18, and 24 months were 83.3%, 75.9%, 54.8%, and 53.9%, respectively. Sixty lesions were upgraded to BI-RADS 4 or 5 during surveillance. Biopsy revealed 15 cancers (cancer yield of 1.47%) from 1017 lesions with either 24-month imaging stability or tissue diagnosis available. Five, six, one, and three cancers were detected at 6, 12, 18, and 24 months, respectively. Cancers were all stage 0 or 1 except for one stage 2A cancer. Seven hundred forty-four of 1188 (62.6%) BI-RADS 3 lesions were downgraded before completing 2-year surveillance. CONCLUSION: Most (11/15 [73%]) breast cancers initially assessed as BI-RADS 3 are diagnosed at up to 12 months' surveillance. Eighteen-month unilateral mammography performed as BI-RADS 3 surveillance contributes minimally to cancer detection and has poor patient compliance.

Interpreting one-view mammographic findings: minimizing callbacks while maximizing cancer detection.

Overlap of breast tissue is a frequent consequence of the necessary positioning and compression of the three-dimensional breast to obtain two-dimensional mammograms. The mammary glands contain fewer anatomically fixed landmarks than solid organs do; thus, variability in positioning can have an even greater effect on mammography than it has on other imaging examinations. Most often, areas of overlapping fibroglandular tissue, also known as summation shadows, are seen on only one of the two standard mammographic views. While striving to detect breast cancer as early as possible, radiologists must learn to visually compensate for apparent abnormalities in the breast that are produced by such tissue overlap. Mammographic interpretation in this setting is made even more challenging by the fact that the only manifestation of breast cancer might be a subtle change on a single mammographic view. Breast cancer might be obscured on one of the two standard views because of the density of surrounding breast tissue, mammographic technique, lesion size or location within the breast, histopathologic characteristics of the tumor, or lack of effect by the tumor on the appearance of surrounding tissues. To heighten awareness of the factors that can lead to either unnecessary recalls or failure to identify breast cancer, cases are reviewed in which false-positive findings and breast cancers were visible on only one mammographic view. Strategies for interpreting screening mammograms and determining which findings merit diagnostic evaluation are outlined so as to help minimize false-positive findings and aid in cancer detection.

Effects of fluvalinate on honey bee learning, memory, responsiveness to sucrose, and survival.

Contaminants can affect organisms' behaviour and, as a consequence, survival. Tau-fluvalinate (hereafter fluvalinate) is the active ingredient in a pesticide commonly used in North America to control Varroa destructor mites in honey bee (Apis mellifera) colonies. Fluvalinate's effects on honey bees are not well known. Honey bee cognitive and neural function can be assessed using the proboscis extension reflex (PER), which applies Pavlovian conditioning techniques. This study used PER to evaluate effects of fluvalinate on honey bee acquisition learning, (long-term) memory recall, responsiveness to sucrose, and mortality. We also evaluated how exclusion criteria for honey bees that did not exhibit PER during training and memory trials affected interpretation of results. Fluvalinate was administered both orally and dermally at high and low doses to mimic routes by which honey bees are exposed. We found negative effects of fluvalinate on honey bee learning, memory, responsiveness to sucrose, and survival, especially in high oral doses. We also found significant consequences to interpretation of results using different exclusion criteria. For example, almost 50% of individuals that failed to show evidence of learning subsequently showed evidence of memory. The latter results have important implications regarding traditional assessment of PER-based learning and memory; the former results suggest that evaluation of honey bee exposure to fluvalinate and attendant consequences warrants further investigation.

Fate of dermally applied miticides fluvalinate and amitraz within honey bee (Hymenoptera: Apidae) bodies.

Varroa mites, Varroa destructor Anderson & Trueman, are economically important pests of honey bees. Varroa mites are principally controlled within honey bee colonies using miticides. However, despite their importance in managing mite populations for apiculture, potential effects of miticides on honey bees are poorly understood. Using gas chromatography-flame ionization detection, we investigated concentrations, over variable time frames and within different body regions, of two commonly used miticides, tau-fluvalinate and amitraz, after dermal exposure to honey bees. We also quantified mortality of honey bees exposed to each miticide at both a low and high dose. Significant differences were observed in distributions of miticides among body regions. Within honey bee body parts, tau-fluvalinate was more readily absorbed and decreased in concentration more rapidly than amitraz. Mortality increased with higher dosages of miticides, and at higher dosages mortality was greater from fluvalinate than from amitraz. For individual honey bees, our results for rate of breakdown suggest that fluvalinate may be the preferred miticide for apiculturists, whereas our mortality results suggest that amitraz may be preferable. Either choice must be weighed against geographic variation in varroa resistance to each pesticide and attendant costs of parasitism.

The proboscis extension reflex to evaluate learning and memory in honeybees (Apis mellifera): some caveats.

The proboscis extension reflex (PER) is widely used in a classical conditioning (Pavlovian) context to evaluate learning and memory of a variety of insect species. The literature is particularly prodigious for honeybees (Apis mellifera) with more than a thousand publications. Imagination appears to be the only limit to the types of challenges to which researchers subject honeybees, including all the sensory modalities and a broad diversity of environmental treatments. Accordingly, some remarkable insights have been achieved using PER. However, there are several challenges to evaluating the PER literature that warrant a careful and thorough review. We assess here variation in methods that makes interpretation of studies, even those researching the same question, tenuous. We suggest that the numerous variables that might influence experimental outcomes from PER be thoroughly detailed by researchers. Moreover, the influence of individual variables on results needs to carefully evaluated, as well as among two or more variables. Our intent is to encourage investigation of the influence of numerous variables on PER results.

Clinical Diagnoses and Outcomes After Diagnostic Breast Ultrasound by Nurses and General Practitioner Physicians in Rural Rwanda.

PURPOSE: To scale up early detection of breast cancer in low- and middle-income countries, research is needed to inform the role of diagnostic breast ultrasound performed by nonradiologists in resource-constrained settings. The authors examined 2-year clinical follow-up and outcomes among women who underwent diagnostic breast ultrasound performed by nonradiologist clinicians participating in a breast ultrasound training and mentorship program at a rural Rwandan hospital. METHODS: Imaging findings, management plans, and pathologic results were prospectively collected during the training using a standardized form. Data on follow-up and outcomes for patients receiving breast ultrasound between January 2016 and March 2017 were retrospectively collected through medical record review. RESULTS: Two hundred twenty-nine breast palpable findings (199 patients) met the study's eligibility criteria. Of 104 lesions initially biopsied, 38 were malignant on initial biopsy; 3 lesions were identified as malignant on repeat biopsy. All 34 patients ultimately diagnosed with cancer received initial recommendations for either biopsy or aspiration by trainees. The positive predictive value of trainee biopsy recommendation was 34.8% (95% confidence interval, 24.8%-45.0%). The sensitivity of trainees' biopsy recommendation for identifying malignant lesions was 92.7% (95% confidence interval, 84.2%-100%). Of 46 patients who did not receive biopsy and were told to return for clinical or imaging follow-up, 37.0% did not return. CONCLUSIONS: Trained nonradiologist clinicians in Rwanda successfully identified suspicious breast lesions on diagnostic breast ultrasound. Loss to follow-up was common among patients instructed to return for surveillance, so lower biopsy thresholds, decentralized surveillance, or patient navigation should be considered for patients with low- or intermediate-suspicion lesions.

Lesion conspicuity on synthetic screening mammography compared to full field digital screening mammography.

OBJECTIVE: To compare lesion conspicuity on synthetic screening mammography (SM) plus digital breast tomosynthesis (DBT) versus full field digital mammography (FFDM) plus DBT. MATERIALS AND METHODS: Seven breast imagers each prospectively evaluated 107-228 screening mammograms (FFDM, DBT, and SM; total 1206 examinations) over 12 weeks in sets of 10-50 consecutive examinations. Interpretation sessions alternated as follows: SM + DBT, then FFDM, or FFDM + DBT, then SM. Lesion conspicuity on SM versus FFDM (equal/better versus less) was assessed using proportions with 95% confidence intervals. DBT-only findings were excluded. RESULTS: Overall 1082 of 1206 (89.7%) examinations were assessed BI-RADS 1/2, and 124 of 1206 (10.3%) assessed BI-RADS 0. There were 409 evaluated findings, including 134 masses, 119 calcifications, 72 asymmetries, 49 architectural distortion, and 35 focal asymmetries. SM conspicuity compared to FFDM conspicuity for lesions was rated 1) masses: 77 (57%) equal or more conspicuous, 57 (43%) less conspicuous; 2) asymmetries/focal asymmetries: 61 (57%) equal or more conspicuous, and 46 (43%) less conspicuous; 3) architectural distortion: 46 (94%) equal or more conspicuous, 3 (6%) less conspicuous; 4) calcifications: 115 (97%) equal or more conspicuous, 4 (3%) less conspicuous. SM had better conspicuity than FFDM for calcifications and architectural distortion and similar conspicuity for most masses and asymmetries. CONCLUSION: Compared to FFDM, SM has better conspicuity for calcifications and architectural distortion and similar conspicuity for most masses and asymmetries.

Training Nonradiologist Clinicians in Diagnostic Breast Ultrasound in Rural Rwanda: Impact on Knowledge and Skills.

OBJECTIVE: To assess the effectiveness of diagnostic breast ultrasound training provided for general practitioners and nurses in Rwanda via intensive in-person and subsequent online supervision and mentorship. METHODS: Four breast radiologists from Brigham and Women's Hospital trained two general practitioner physicians and five nurses in Rwanda over 9 total weeks of in-person training and 20 months of remote mentorship using electronic image review with emailed feedback. Independently recorded assessments were compared to calculate the sensitivity and specificity of trainee assessments, with radiologist assessments as the gold standard. We compared performance in the first versus second half of the training. RESULTS: Trainees' performance on written knowledge assessments improved after training (57.7% versus 98.1% correct, P = .03). Mean sensitivity of trainee-performed ultrasound for identifying a solid breast mass was 90.6% (SD 4.2%) in the first half of the training (period 1) and 94.0% (SD 6.7%) in period 2 (P = .32). Mean specificity was 94.7% (SD 5.4%) in period 1 and 100.0% (SD 0) in period 2 (P = .10). Mean sensitivity for identifying a medium- or high-suspicion solid mass increased from 79.2% (SD 11.0%) in period 1 to 96.3% (SD 6.4%) in period 2 (P = .03). Specificity was 84.4% (SD 15.0%) in period 1 and 96.7% (SD 5.8%) in period 2 (P = .31). DISCUSSION: Nonradiologist clinicians (doctors and nurses) in a rural sub-Saharan African hospital built strong skills in diagnostic breast ultrasound over 23 months of combined in-person training and remote mentorship. The sensitivity of trainees' assessments in identifying masses concerning for malignancy improved after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.

Factors that impact the duration of MRI-guided core needle biopsy.

OBJECTIVE: The purpose of our study was to determine which patient-related, target lesion-related, or procedure-related variables impact the duration of MRI-guided core needle breast biopsy. MATERIALS AND METHODS: Between July 11, 2006, and September 26, 2007, data were collected for 75 single-target MRI-guided 9-gauge vacuum-assisted core needle biopsy procedures using a grid-guidance technique and performed at a single institution. The following variables were studied: MRI suite occupation time, number of operators, patient age and breast size, target morphology and location, approach to target, equipment used, number of image acquisitions and times the patient was moved in and out of the closed magnet, and occurrence of complications. Statistical analysis was performed using the Student's t test, analysis of variance, and Pearson's correlation, with p values < 0.05 considered significant. RESULTS: The mean duration was 57.9 minutes (SD, 17.2 minutes; range, 30-109 minutes). None of the patient- or target-related variables significantly impacted the duration, although lesions located in the anterior third of the breast showed a trend to prolong the procedure (p = 0.059). The time to complete a procedure was reduced when the operating radiologist was assisted by a breast imaging fellow-in-training (p = 0.01). Increasing numbers of image acquisitions and times the patient was moved in and out of the magnet significantly lengthened the procedure duration (p = 0.0001 for both). No major complications occurred. Biopsies yielded 16% (12/75) malignant and 84% (63/75) benign diagnoses. CONCLUSION: Variables that minimized procedure duration were number of image acquisitions, number of patient insertions or removals from the magnet, and assistance of a breast imaging fellow-in-training. No patient-related or target-related variables impacted procedure time.

Experience of physician and nurse specialists in Sweden undertaking long distance aeromedical transportation of critically ill patients: A qualitative study.

INTRODUCTION: Transportation of critically ill patients, intra- or inter-hospital, always involves risks when resources are limited. With aeromedical transports, additional risk factors are incurred. The physiological effects of altitude, when both pressure and density decline, can lead to hypobaric hypoxia and gases trapped in body cavities will expand and cause stress on biological tissue. AIM: The aim of this study was to explore the experiences of nurse and physician specialists in Sweden undertaking long distance aeromedical transport of critically ill patients, with a flight time of more than two hours. METHOD: A qualitative approach with a descriptive design. Thirteen recorded semi-structured interviews with physician and nurse specialists were analyzed using inductive qualitative content analysis. RESULTS: One overall theme emerged, To be one step ahead to ensure patient safety in the air; with three categories 1) With the patient in focus, 2) To be part of a team and concerned about patient safety and 3) To be in need of recovery. CONCLUSION: This study demonstrates the challenges with long distance aeromedical transport of critically ill patients. The healthcare personnel make decisions and actions to be one step ahead to ensure patient safety. This isolated work is improved with experience, education, training and good communication skills.

Optimizing Success and Avoiding Mishaps in the Most Difficult Image-guided Breast Biopsies.

Breast cancer is an increasing challenge in developed and limited resource areas of the world. Early detection of breast cancer offers the best chance for optimal care and best outcomes. A critical step in early detection is to obtain efficient and accurate tissue diagnoses. Although image-guided core needle breast biopsies are usually straightforward for experienced breast imagers, there are some not uncommon scenarios that present particular challenges. In this review article we will discuss these difficult situations and offer our tried and true methods to ensure safe and successful biopsies, while using stereotactic, ultrasound, and MRI guidance.

Avoiding Pitfalls, Maximizing Success at Image-guided Breast Interventions: A Pictorial Review.

Imaging and image-guided interventions have become increasingly important in the workup and treatment of breast lesions in the past 2 decades. Radiologists should be aware of potential pitfalls during the workup, the procedure itself, and in the postprocedure follow-up. In this pictorial review, we illustrate challenges related to technique and interpretation related to breast interventions, and suggest ways to maximize success.

Behavioral response of Corophium volutator to shorebird predation in the upper Bay of Fundy, Canada.

Predator avoidance is an important component of predator-prey relationships and can affect prey availability for foraging animals. Each summer, the burrow-dwelling amphipod Corophium volutator is heavily preyed upon by Semipalmated Sandpipers (Calidris pusilla) on mudflats in the upper Bay of Fundy, Canada. We conducted three complementary studies to determine if adult C. volutator exhibit predator avoidance behavior in the presence of sandpipers. In a field experiment, we monitored vertical distribution of C. volutator adults in bird exclosures and adjacent control plots before sandpipers arrived and during their stopover. We also made polymer resin casts of C. volutator burrows in the field throughout the summer. Finally, we simulated shorebird pecking in a lab experiment and observed C. volutator behavior in their burrows. C. volutator adults were generally distributed deeper in the sediment later in the summer (after sandpipers arrived). In August, this response was detectably stronger in areas exposed to bird predation than in bird exclosures. During peak predator abundance, many C. volutator adults were beyond the reach of feeding sandpipers (>1.5 cm deep). However, burrow depth did not change significantly throughout the summer. Detailed behavioral observations indicated that C. volutator spent more time at the bottom of their burrow when exposed to a simulated predator compared to controls. This observed redistribution suggests that C. volutator adults move deeper into their burrows as an anti-predator response to the presence of sandpipers. This work has implications for predators that feed on burrow-dwelling invertebrates in soft-sediment ecosystems, as density may not accurately estimate prey availability.

Difficulties and errors in diagnosis of breast neoplasms.

Many perceptual and interpretive factors influence the radiologic detection and assessment of breast neoplasms. Diagnostic problems can be divided into errors of detection and errors of assessment and management. Detection issues may relate to inherent features of the tumor or surrounding tissue, technical problems, or human error. Even when lesions are successfully detected, errors in assessment or management recommendations can cause diagnostic delays. Improper breast imaging-reporting and data system (BI-RADS) usage or failure to integrate mammographic, ultrasonography (US), and magnetic resonance imaging (MRI) findings with clinical findings, all lead to interpretive errors. This article reviews factors affecting the detection and diagnosis of breast cancer, to improve radiologic interpretation, benefit patients by earlier cancer detection, and lessen medicolegal exposure from a missed or delayed cancer diagnosis. Mammography is the primary imaging modality for population-based breast cancer screening, and it is also the usual initial examination performed for diagnostic evaluation of clinical or screen-detected breast abnormalities in women aged 40 years and older. Mammography is supplemented by breast US and/or breast MRI in some cases. This article will, therefore, focus on mammography in reviewing difficulties and errors in cancer diagnosis, with supplemental discussion of breast US and breast MRI.