Assessing the Relationship between Radiology Department Research Funding and Institutional Community Inclusion and Investment.

Background Health care access disparities and lack of inclusion in clinical research have been well documented for marginalized populations. However, few studies exist examining the research funding of institutions that serve historically underserved groups. Purpose To assess the relationship between research funding awarded to radiology departments by the National Institutes of Health (NIH) and Lown Institute Hospitals Index rankings for inclusivity and community benefit. Materials and Methods This retrospective study included radiology departments awarded funding from the NIH between 2017 and 2021. The 2021 Lown Institute Hospitals Index rankings for inclusivity and community benefit were examined. The inclusivity metric measures how similar a hospital's patient population is to the surrounding community in terms of income, race and ethnicity, and education level. The community benefit metric measures charity care spending, Medicaid as a proportion of patient revenue, and other community benefit spending. Linear regression and Pearson correlation coefficients (r values) were used to evaluate the relationship between aggregate NIH radiology department research funding and measures of inclusivity and community benefit. Results Seventy-five radiology departments that received NIH funding ranging from $195 000 to $216 879 079 were included. A negative correlation was observed between the amount of radiology department research funding received and institutional rankings for serving patients from racial and/or ethnic minorities (r = -0.34; P < .001), patients with low income (r = -0.44; P < .001), and patients with lower levels of education (r = -0.46; P < .001). No correlation was observed between the amount of radiology department research funding and institutional rankings for charity care spending (r = -0.19; P = .06), community investment (r = -0.04; P = .68), and Medicaid as a proportion of patient revenue (r = -0.10; P = .22). Conclusion Radiology departments that received more NIH research funding were less likely to serve patients from racial and/or ethnic minorities and patients who had low income or lower levels of education. © RSNA, 2024 See also the editorial by Mehta and Rosen in this issue.

Practical Approaches to Advancing Health Equity in Radiology, From the AJR Special Series on DEI.

Despite significant advances in health care, many patients from medically under-served populations are impacted by existing health care disparities. Radiologists are uniquely positioned to decrease health disparities and advance health equity efforts in their practices. However, literature on practical tools for advancing radiology health equity efforts applicable to a wide variety of patient populations and care settings is lacking. Therefore, this article seeks to equip radiologists with an evidence-based and practical knowledge tool kit of health equity strategies, presented in terms of four pillars of research, clinical care, education, and innovation. For each pillar, equity efforts across diverse patient populations and radiology practice settings are examined through the lens of existing barriers, current best practices, and future directions, incorporating practical examples relevant to a spectrum of patient populations. Health equity efforts provide an opportune window to transform radiology through personalized care delivery that is responsive to diverse patient needs. Guided by compassion and empathy as core principles of health equity, the four pillars provide a helpful framework to advance health equity efforts as a step toward social justice in health.

Fostering Patient-Centered Equitable Care in Radiology: AJR Expert Panel Narrative Review.

Patient-centered care (PCC) and equity are two of the six core domains of quality health care, according to the Institute of Medicine. Exceptional imaging care requires radiology practices to provide patient-centered (i.e., respectful and responsive to individual patient preferences, needs, and values) and equitable (i.e., does not vary in quality on the basis of gender, ethnicity, geographic location, or socioeconomic status) care. Specific barriers that prevent the delivery of patient-centered equitable care include information gaps, breaches of trust, organizational medical culture, and financial incentives. Information gaps limit practitioners in understanding the lived experience of patients. Breaches of trust prevent patients from seeking needed medical care. Organizational medical cultures may not be centered around patient experiences. Financial incentives can impede practitioners' ability to spend the time and resources required to meet patient goals and needs. Intentional approaches that integrate core principles in both PCC and health equity are required to deliver high-quality patient-centered imaging care for diverse patient populations. The purpose of this AJR Expert Panel Narrative Review is to review the origins of the PCC movement in radiology, characterize connections between the PCC and health equity movements, and describe concrete examples of ways to foster patient-centered equitable care in radiology.

Breast Imaging and Intervention during Pregnancy and Lactation.

Physiologic changes that occur in the breast during pregnancy and lactation create challenges for breast cancer screening and diagnosis. Despite these challenges, imaging evaluation should not be deferred, because delayed diagnosis of pregnancy-associated breast cancer contributes to poor outcomes. Both screening and diagnostic imaging can be safely performed using protocols based on age, breast cancer risk, and whether the patient is pregnant or lactating. US is the preferred initial imaging modality for the evaluation of clinical symptoms in pregnant women, followed by mammography if the US findings are suspicious for malignancy or do not show the cause of the clinical symptom. Breast MRI is not recommended during pregnancy because of the use of intravenous gadolinium-based contrast agents. Diagnostic imaging for lactating women is the same as that for nonpregnant nonlactating individuals, beginning with US for patients younger than 30 years old and mammography followed by US for patients aged 30 years and older. MRI can be performed for high-risk screening and local-regional staging in lactating women. The radiologist may encounter a wide variety of breast abnormalities, some specific to pregnancy and lactation, including normal physiologic changes, benign disorders, and malignant neoplasms. Although most masses encountered are benign, biopsy should be performed if the imaging characteristics are suspicious for cancer or if the finding does not resolve after a short period of clinical follow-up. Knowledge of the expected imaging appearance of physiologic changes and common benign conditions of pregnancy and lactation is critical for differentiating these findings from pregnancy-associated breast cancer. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Community-based Participatory Research: A Practical Guide for Radiologists.

Community-based participatory research (CBPR) is defined by the Kellogg Community Health Scholars Program as a collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each community member brings. The CBPR process begins with a research topic of importance to the community, with the goal of combining knowledge and action with social change to improve community health and eliminate health disparities. CBPR engages and empowers affected communities to collaborate in defining the research question; sharing the study design process; collecting, analyzing, and disseminating the data; and implementing solutions. A CBPR approach in radiology has several potential applications, including removing limitations to high-quality imaging, improving secondary prevention, identifying barriers to technology access, and increasing diversity in the research participation for clinical trials. The authors provide an overview with the definitions of CBPR, explain how to conduct CBPR, and illustrate its applications in radiology. Finally, the challenges of CBPR and useful resources are discussed in detail. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic.

BACKGROUND. The need for second visits between screening mammography and diagnostic imaging contributes to disparities in the time to breast cancer diagnosis. During the COVID-19 pandemic, an immediate-read screening mammography program was implemented to reduce patient visits and decrease time to diagnostic imaging. OBJECTIVE. The purpose of this study was to measure the impact of an immediate-read screening program with focus on disparities in same-day diagnostic imaging after abnormal findings are made at screening mammography. METHODS. In May 2020, an immediate-read screening program was implemented whereby a dedicated breast imaging radiologist interpreted all screening mammograms in real time; patients received results before discharge; and efforts were made to perform any recommended diagnostic imaging during the visit (performed by different radiologists). Screening mammographic examinations performed from June 1, 2019, through October 31, 2019 (preimplementation period), and from June 1, 2020, through October 31, 2020 (postimplementation period), were retrospectively identified. Patient characteristics were recorded from the electronic medical record. Multivariable logistic regression models incorporating patient age, race and ethnicity, language, and insurance type were estimated to identify factors associated with same-day diagnostic imaging. Screening metrics were compared between periods. RESULTS. A total of 8222 preimplementation and 7235 postimplementation screening examinations were included; 521 patients had abnormal screening findings before implementation, and 359 after implementation. Before implementation, 14.8% of patients underwent same-day diagnostic imaging after abnormal screening mammograms. This percentage increased to 60.7% after implementation. Before implementation, patients who identified their race as other than White had significantly lower odds than patients who identified their race as White of undergoing same-day diagnostic imaging after receiving abnormal screening results (adjusted odds ratio, 0.30; 95% CI, 0.10-0.86; p = .03). After implementation, the odds of same-day diagnostic imaging were not significantly different between patients of other races and White patients (adjusted odds ratio, 0.92; 95% CI, 0.50-1.71; p = .80). After implementation, there was no significant difference in race and ethnicity between patients who underwent and those who did not undergo same-day diagnostic imaging after receiving abnormal results of screening mammography (p > .05). The rate of abnormal interpretation was significantly lower after than it was before implementation (5.0% vs 6.3%; p < .001). Cancer detection rate and PPV1 (PPV based on positive findings at screening examination) were not significantly different before and after implementation (p > .05). CONCLUSION. Implementation of the immediate-read screening mammography program reduced prior racial and ethnic disparities in same-day diagnostic imaging after abnormal screening mammograms. CLINICAL IMPACT. An immediate-read screening program provides a new paradigm for improved screening mammography workflow that allows more rapid diagnostic workup with reduced disparities in care.

Lung cancer screening eligibility and use with low-dose computed tomography: Results from the 2018 Behavioral Risk Factor Surveillance System cross-sectional survey.

BACKGROUND: In randomized controlled trials, lung cancer screening with low-dose chest computed tomography (LCS) has been reported to reduce lung cancer mortality. Although initial studies suggested that only approximately 5% of eligible patients have undergone LCS, recent studies have indicated that use of LCS may be increasing nationwide. The objective of the current study was to estimate recent LCS use using cross-sectional survey data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey. METHODS: The BRFSS is a nationally representative, cross-sectional telephone survey of adults in the United States (response rate of approximately 50%). The 2018 BRFSS survey included questions regarding LCS eligibility and use in 8 states. The primary outcome was the percentage of participants (aged 55-79 years with a smoking history of >30 pack-years) who reported undergoing LCS. Logistic regression analyses evaluated the association between LCS use and sociodemographic characteristics, adjusted for potential confounders and accounting for complex survey design elements. RESULTS: A total of 26,910 participants were included, 9.9% of whom were eligible for LCS (95% CI, 8.8%-10.6%). Of the eligible patients, 19.2% reported undergoing LCS (95% CI, 14.0%-24.4%). Approximately 16.4% of current smokers were eligible for LCS (95% CI, 14.2%-18.6%). In our multiple variable analyses of eligible patients, age, sex, marital status, current smoking status, and race were not found to be associated with statistically significant differences in reported LCS (P > .05). Retired patients, patients with personal physicians, and patients who did not complete a high school education were more likely to report receiving LCS (P < .05). CONCLUSIONS: Compared with previously published studies, the results of the current study suggested that LCS use is increasing. However, LCS use remains low (19%) among eligible participants.

Potential of using mammography screening appointments to identify high-risk women: cross sectional survey results from the national health interview survey.

PURPOSE: Mammography screening encounters may represent ideal opportunities to identify high-risk women for risk-based screening. During mammography appointments, radiology practices evaluate breast density and ascertain known breast cancer risk factors. Our purpose was to evaluate the potential for mammographic screening encounters to identify high-risk women by estimating the (1) proportion of high-risk women who report that they have undergone mammographic screening and the (2) proportion of high-risk women who receive recommendations for breast MRI screening. METHODS: Women ages 30-85 without breast cancer histories were included from the 2015 National Health Interview Survey, a nationally representative cross-sectional household survey (response rate 80%). Breast Cancer Risk Assessment Tool was used to determine high-risk (lifetime risk>20%). Among high-risk women, primary outcome was proportion reporting mammography screening, secondary outcome was receipt of a breast MRI recommendation after recent mammogram, accounting for complex survey design. RESULTS: 14,958 women were included. 1.0% were high-risk of whom: 91.9% ever had a mammogram, 68.0% had a mammogram within the last year, 81.5% had a mammogram within the last 2 years. 6.4% were recommended to undergo breast MRI. Among high-risk women, women with dense breast tissue were more likely (OR 496.0, 95%CI 52.6,4674.0) and older women were less likely (OR 0.91, 95%CI 0.84,0.99) to receive recommendations for breast MRI. CONCLUSIONS: Among high-risk women, 92% reported undergoing at least one mammogram in their lives. 94% did not receive recommendations for breast MRI screening and 32% did not have a mammogram within the last year. To identify high-risk women, breast imaging centers should consider determining lifetime breast cancer risk during mammography screening visits.

Racial and Ethnic Disparities in Lung Cancer Screening Eligibility.

Background To address disparities in lung cancer screening (LCS) that may exclude large numbers of high-risk African American smokers, revised U.S. Preventive Services Task Force (USPSTF) recommendations lowered LCS eligibility thresholds. However, there are limited recent data about the impact of newly revised guidelines on disparities in LCS eligibility. Purpose To evaluate the impact of revised USPSTF guidelines on racial and ethnic disparities in LCS eligibility. Materials and Methods Cross-sectional survey data from 20 states were retrospectively evaluated from the 2019 Behavioral Risk Factor Surveillance System survey (median response rate, 49.4%). Respondents without a history of lung cancer aged 55-79 years (ie, under the previous guidelines) or aged 50-79 years (ie, under the revised guidelines) were included. Multivariable logistic regression analyses were performed to evaluate the association between race and ethnicity and LCS eligibility. All analyses were performed accounting for complex survey design features (ie, weighting, stratification, and clustering). Results Under previous guidelines, 11% of 67 567 weighted survey respondents were eligible for LCS (White [12%], Hispanic [4%], African American [7%], American Indian [17%], Asian or Pacific Islander [4%], and other [12%]). Under revised USPSTF guidelines, 14% of 77 689 weighted survey respondents were eligible for LCS (White [15%], Hispanic [5%], African American [9%], American Indian [21%), Asian or Pacific Islander [5%], and other [18%]). Compared with White respondents, African American respondents (adjusted odds ratio [OR] = 0.36; 95% CI: 0.27, 0.47; P < .001) and Hispanic respondents (adjusted OR = 0.15; 95% CI: 0.09, 0.24; P < .001) were less likely to be eligible for LCS under previous guidelines. African American respondents (adjusted OR = 0.39; 95% CI: 0.32, 0.47; P < .001) and Hispanic respondents (adjusted OR = 0.15; 95% CI: 0.10, 0.23; P < .001) were less likely to be eligible under the revised guidelines. The Wald test showed no evidence of differences in the degree to which racial and ethnic minority groups were less likely to be eligible for LCS when comparing previous versus revised USPSTF guidelines (P = .76). Conclusion The revised U.S. Preventive Services Task Force guidelines (version 2.0) may perpetuate lung cancer disparities, as racial and ethnic minority groups are still less likely to be eligible for lung cancer screening. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Jacobs and Springfield in this issue.

Comparison of Chest CT Findings of COVID-19, Influenza, and Organizing Pneumonia: A Multireader Study.

BACKGROUND. Previous studies compared CT findings of COVID-19 pneumonia with those of other infections; however, to our knowledge, no studies to date have included noninfectious organizing pneumonia (OP) for comparison. OBJECTIVE. The objectives of this study were to compare chest CT features of COVID-19, influenza, and OP using a multireader design and to assess the performance of radiologists in distinguishing between these conditions. METHODS. This retrospective study included 150 chest CT examinations in 150 patients (mean [± SD] age, 58 ± 16 years) with a diagnosis of COVID-19, influenza, or non-infectious OP (50 randomly selected abnormal CT examinations per diagnosis). Six thoracic radiologists independently assessed CT examinations for 14 individual CT findings and for Radiological Society of North America (RSNA) COVID-19 category and recorded a favored diagnosis. The CT characteristics of the three diagnoses were compared using random-effects models; the diagnostic performance of the readers was assessed. RESULTS. COVID-19 pneumonia was significantly different (p < .05) from influenza pneumonia for seven of 14 chest CT findings, although it was different (p < .05) from OP for four of 14 findings (central or diffuse distribution was seen in 10% and 7% of COVID-19 cases, respectively, vs 20% and 21% of OP cases, respectively; unilateral distribution was seen in 1% of COVID-19 cases vs 7% of OP cases; non-tree-in-bud nodules was seen in 32% of COVID-19 cases vs 53% of OP cases; tree-in-bud nodules were seen in 6% of COVID-19 cases vs 14% of OP cases). A total of 70% of cases of COVID-19, 33% of influenza cases, and 47% of OP cases had typical findings according to RSNA COVID-19 category assessment (p < .001). The mean percentage of correct favored diagnoses compared with actual diagnoses was 44% for COVID-19, 29% for influenza, and 39% for OP. The mean diagnostic accuracy of favored diagnoses was 70% for COVID-19 pneumonia and 68% for both influenza and OP. CONCLUSION. CT findings of COVID-19 substantially overlap with those of influenza and, to a greater extent, those of OP. The diagnostic accuracy of the radiologists was low in a study sample that contained equal proportions of these three types of pneumonia. CLINICAL IMPACT. Recognized challenges in diagnosing COVID-19 by CT are furthered by the strong overlap observed between the appearances of COVID-19 and OP on CT. This challenge may be particularly evident in clinical settings in which there are substantial proportions of patients with potential causes of OP such as ongoing cancer therapy or autoimmune conditions.

Racial and Ethnic Disparities in Disease Severity on Admission Chest Radiographs among Patients Admitted with Confirmed Coronavirus Disease 2019: A Retrospective Cohort Study.

Background Disease severity on chest radiographs has been associated with higher risk of disease progression and adverse outcomes from coronavirus disease 2019 (COVID-19). Few studies have evaluated COVID-19-related racial and/or ethnic disparities in radiology. Purpose To evaluate whether non-White minority patients hospitalized with confirmed COVID-19 infection presented with increased severity on admission chest radiographs compared with White or non-Hispanic patients. Materials and Methods This single-institution retrospective cohort study was approved by the institutional review board. Patients hospitalized with confirmed COVID-19 infection between March 17, 2020, and April 10, 2020, were identified by using the electronic medical record (n = 326; mean age, 59 years ±17 [standard deviation]; male-to-female ratio: 188:138). The primary outcome was the severity of lung disease on admission chest radiographs, measured by using the modified Radiographic Assessment of Lung Edema (mRALE) score. The secondary outcome was a composite adverse clinical outcome of intubation, intensive care unit admission, or death. The primary exposure was the racial and/or ethnic category: White or non-Hispanic versus non-White (ie, Hispanic, Black, Asian, or other). Multivariable linear regression analyses were performed to evaluate the association between mRALE scores and race and/or ethnicity. Results Non-White patients had significantly higher mRALE scores (median score, 6.1; 95% confidence interval [CI]: 5.4, 6.7) compared with White or non-Hispanic patients (median score, 4.2; 95% CI: 3.6, 4.9) (unadjusted average difference, 1.8; 95% CI: 0.9, 2.8; P < .01). For both White (adjusted hazard ratio, 1.3; 95% CI: 1.2, 1.4; P < .001) and non-White (adjusted hazard ratio, 1.2; 95% CI: 1.1, 1.3; P < .001) patients, increasing mRALE scores were associated with a higher likelihood of experiencing composite adverse outcome with no evidence of interaction (P = .16). Multivariable linear regression analyses demonstrated that non-White patients presented with higher mRALE scores at admission chest radiography compared with White or non-Hispanic patients (adjusted average difference, 1.6; 95% CI: 0.5, 2.7; P < .01). Adjustment for hypothesized mediators revealed that the association between race and/or ethnicity and mRALE scores was mediated by limited English proficiency (P < .01). Conclusion Non-White patients hospitalized with coronavirus disease 2019 infection were more likely to have a higher severity of disease on admission chest radiographs than White or non-Hispanic patients, and increased severity was associated with worse outcomes for all patients. © RSNA, 2020 Online supplemental material is available for this article.

Lung Cancer Screening Eligibility and Utilization Among Transgender Patients: An Analysis of the 2017-2018 United States Behavioral Risk Factor Surveillance System Survey.

INTRODUCTION: Transgender and gender diverse (TGD) persons disproportionately face many health disparities including a higher risk of lung cancer. Lung cancer screening (LCS) using low-dose chest computed tomography has reduced lung cancer mortality in eligible high-risk smokers across several large trials, yet utilization of LCS remains low. TGD persons may be less likely to receive recommended cancer screening compared with cisgender populations. We sought to compare eligibility for and utilization of LCS between TGD and cisgender persons in the United States. We also examined if the utilization of LCS varied by smoking status within each gender identity group. METHODS: We analyzed data from the 2017 and 2018 Behavioral Risk Factor Surveillance System (BRFSS) cross-sectional survey to determine eligibility and utilization of LCS among TGD participants compared with cisgender persons. Logistical regression analysis of potentially confounding variables included age category, race/ethnicity, income, employment status, health insurance, and having a personal doctor. RESULTS: Of 37 023 weighted respondents, 0.5% were TGD. Although eligibility for LCS was statistically similar (8.8% TGD vs. 12.2% cisgender) (adjusted odds ratio = 0.81, 95% confidence interval = 0.27-2.39, p = .703), only 2.3% of TGD participants reported obtaining a LCS chest computed tomography versus 17.2% of cisgender participants (adjusted odds ratio = 0.04, 95% confidence interval = 0.01-0.59, p = .019). Smoking status showed no association with LCS utilization among gender identity groups. CONCLUSIONS: TGD persons may be less likely to receive LCS despite having similar smoking status and eligibility of cisgender persons, suggesting a disparity in utilization of this preventative health service. IMPLICATIONS: Targeted efforts to increase LCS utilization and promote smoking cessation for at-risk TGD patients may be warranted.

Obesity and breast cancer screening: Cross-sectional survey results from the behavioral risk factor surveillance system.

BACKGROUND: Postmenopausal obese women demonstrate an elevated breast cancer risk and experience increased breast cancer morbidity and mortality compared with women with a normal body mass index (BMI). However, to the authors' knowledge, prior studies have yielded inconclusive results regarding the effects of obesity on mammography screening adherence. Using national cross-sectional survey data, the objective of the current study was to assess the current association between increasing BMI and use of mammography screening. METHODS: Cross-sectional survey data from the 2016 Behavioral Risk Factor Surveillance System, a state-based national telephone survey of noninstitutionalized adults in the United States, was used to identify the association between mammography screening use and increasing incremental BMI categories, including normal (18.5-24.9 kg/m2 ), overweight (25-29.9 kg/m2 ), obese class I (30-34.9 kg/m2 ), obese class II (35-39.9 kg/m2 ), and obese class III (>40 kg/m2 ), with adjustments for potential confounders. A multivariable logistic regression model was used to evaluate the effect of each BMI category on self-reported mammography use, using unadjusted and adjusted odds ratios. Effect modification by race/ethnicity was determined by testing interaction terms using Wald tests. RESULTS: Of 116,343 survey respondents, 33.5% (38,984 respondents) had a normal BMI, 32.6% (37,969 respondents) were overweight, 19.3% (22,416 respondents) were classified as obese class I, 8.4% (9791 respondents) were classified as obese class II, and 6.2% (7183 respondents) were classified as obese class III. There was no statistically significant difference (P < .05) observed with regard to mammography use between women with a normal BMI and obese women from each obese class (classes I-III) when compared individually. There also was no evidence of effect modification by race (P = .53). CONCLUSIONS: In contrast to prior reports, the results of the current study demonstrated no association between obesity and adherence to screening mammography. These findings may relate to the increasing social acceptance of obesity among women from all racial/ethnic groups and the removal of weight-related facility-level barriers over time.

Quantifying performance thresholds for recommending screening mammography: a revealed preference analysis of USPSTF guidelines.

PURPOSE: During ongoing controversies about mammography screening, many investigators have stated that performance improvements in screening mammography may mitigate concerns about harms. However, there have been few attempts to quantify performance improvements required to recommend mammography screening. Based on USPSTF benchmarks, we utilized revealed preference methods to ascertain quantitative thresholds at which screening mammography would be recommended beyond biennial screening in women 50 and older. METHODS: Benefits of routine screening mammography (breast cancer deaths averted) were from published USPSTF meta-analyses. Potential harms (10-year cumulative probability of at least one false-positive) were from published Breast Cancer Surveillance Consortium estimates. We identified the implicit threshold (benefit/harm ratio) to recommend biennial screening starting at age 50. Using this threshold, we ascertained reductions of false-positives required to recommend more frequent screening and screening initiation under age 50 using revealed preference analyses. RESULTS: Using USPSTF implied benefit/harm ratio, routine biennial screening would be recommended starting at 40 if false-positives declined by at least 62%. Reductions of false-positive proportions of 74% would be required to recommend annual screening starting at 40 and reductions of false-positive proportions of 31% would be required to support annual screening starting at 50. CONCLUSIONS: Using USPSTF revealed preferences, 31-74% reductions in false-positives would be required to recommend mammography screening beyond biennial screening starting at age 50. Widespread implementation of tomosynthesis and reducing recall rates to the lower end of recommended recall rates (5-12%) would provide support for expanding screening beyond biennial screening in women age 50.