Breast Cancer Screening and BI-RADS Scoring Trends Before and During the COVID-19 Pandemic in an Academic Safety-Net Hospital.

BACKGROUND: Little is known about how the COVID-19 pandemic affected screening mammography rates and Breast Imaging Reporting and Data Systems (BI-RADS) categorizations within populations facing social and economic inequities. Our study seeks to compare trends in breast cancer screening and BI-RADS assessments in an academic safety-net patient population before and during the COVID-19 pandemic. PATIENTS AND METHODS: Our single-center retrospective study evaluated women ≥ 18 years old with no known breast cancer diagnosis who received breast cancer screening from March 2019-September 2020. The screening BI-RADS score, completion of recommended diagnostic imaging, and diagnostic BI-RADS scores were compared between the pre-COVID-19 era (from 1 March 2019 to 19 March 2020) and COVID-19 era (from 20 March 2020 to 30 September 2020). RESULTS: Among the 11,798 patients identified, screened patients were younger (median age 57 versus 59 years, p < 0.001) and more likely covered by private insurance (35.9% versus 32.3%, p < 0.001) during the COVID-19 era compared with the pre-COVID-19 era. During the pandemic, there was an increase in screening mammograms categorized as BI-RADS 0 compared with the pre-COVID-19 era (20% versus 14.5%, p < 0.0001). There was no statistically significant difference in rates of completion of diagnostic imaging (81.6% versus 85.4%, p = 0.764) or assignment of suspicious BI-RADS scores (BI-RADS 4-5; 79.9% versus 80.8%, p = 0.762) between the two eras. CONCLUSIONS: Although more patients were recommended to undergo diagnostic imaging during the pandemic, there were no significant differences in race, completion of diagnostic imaging, or proportions of mammograms categorized as suspicious between the two time periods. These findings likely reflect efforts to maintain equitable care among diverse racial groups served by our safety-net hospital.

Comparison of Contrast-enhanced Mammography with MRI Utilizing an Enriched Reader Study: A Breast Cancer Study (CONTRRAST Trial).

Background Despite growing interest in using contrast-enhanced mammography (CEM) for breast cancer screening as an alternative to breast MRI, limited literature is available. Purpose To determine whether CEM is noninferior to breast MRI or abbreviated breast MRI (AB MRI) and superior to two-dimensional mammography in an asymptomatic population simulating those who would present for screening and then undergo diagnostic work-up. Materials and Methods This enriched reader study used CEM and MRI data prospectively collected from asymptomatic individuals at a single institution from December 2014 to March 2020. Case sets were obtained at screening, as part of work-up for a screening-detected finding, or before biopsy of a screening-detected abnormality. All images were anonymized and randomized, and all 12 radiologists interpreted them. For CEM interpretation, readers were first shown low-energy images as a surrogate for digital mammography and asked to give a forced Breast Imaging Reporting and Data System score for up to three abnormalities. The highest score was used as the case score. Readers then reviewed the full CEM examination and scored it similarly. After a minimum 1-month washout, the readers similarly interpreted AB MRI and full MRI examinations. Receiver operating characteristic analysis, powered to test CEM noninferiority to full MRI, was performed. Results The study included 132 case sets (14 negative, 74 benign, and 44 malignant; all female participants; mean age, 54 years ± 12 [SD]). The mean areas under the receiver operating characteristic curve (AUCs) for digital mammography, CEM, AB MRI, and full MRI were 0.79, 0.91, 0.89, and 0.91, respectively. CEM was superior to digital mammography (P < .001). No evidence of a difference in AUC was found between CEM and AB MRI and MRI. Conclusion In an asymptomatic study sample, CEM was noninferior to full MRI and AB MRI and was superior to digital mammography. Clinical trial registration no. NCT03482557 and NCT02275871 © RSNA, 2023 Supplemental material is available for this article.

Imaging and Management of Radial Scars and Complex Sclerosing Lesions.

Radial scars and complex sclerosing lesions, often collectively referred to as radial sclerosing lesions (RSLs), are breast lesions characterized by sclerotic stroma with entrapped epithelial elements. RSLs have imaging features that overlap with those of breast malignancy and often become the target of imaging-guided biopsy given their suspicious imaging appearance. These can be identified in isolation or can also be associated with atypia or other high-risk lesions that have intrinsic malignant potential, increasing the risk of carcinoma and affecting prognosis and management of RSLs. Because of this, management of these lesions remains controversial. Traditional management has been surgical excisional biopsy. However, as more RSLs are identified (because digital breast tomosynthesis allows identification of more architectural distortions), optimal management is evolving. Physicians in some practices are using a multidisciplinary approach to the management of RSLs when deciding on surgical excision of these lesions versus imaging follow-up. These discussions also incorporate individual patient risk factors and greater patient informed medical decision making. Reported upgrade rates of RSLs at core needle biopsy vary and can depend on the sampling method, number of samples, gauge of the needle, target being sampled, and radiologic-pathologic concordance or discordance. A precise sampling technique also allows greater accuracy of diagnosis and lower upgrade rates for these lesions, with radiologic-pathologic correlation as an integral component for further management decisions. The authors review the overall histopathologic, clinical, and imaging features of RSLs and discuss appropriate management based on currently available data regarding upgrade rates. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Enhancement Type at Contrast-enhanced Mammography and Association with Malignancy.

Background Despite the increasing use of contrast-enhanced mammography (CEM), there are limited data on the evaluation of findings on recombined images and the association with malignancy. Purpose To determine the rates of malignancy of enhancement findings on CEM images in the presence or absence of low-energy findings using the Breast Imaging Reporting and Data System (BI-RADS) lexicon developed for mammography and MRI. Materials and Methods All diagnostic CEM examinations performed at one academic institution between December 2015 and December 2019 had low-energy and recombined images retrospectively. Data were independently reviewed by three breast imaging radiologists with 5-25 years of experience using the BI-RADS mammography and MRI lexicon. Outcome was determined with pathologic analysis or 1-year imaging or clinical follow-up. The χ2 and Fisher exact tests were used for analysis. Results A total of 371 diagnostic CEM studies were performed in 371 women (mean age, 54 years ± 11[SD]). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value of enhancement on CEM images was 95% (104 of 109 [95% CI: 90, 98]), 67% (176 of 262 [95% CI: 61, 73]), 55% (104 of 190 [95% CI: 47, 62]), and 97% (176 of 181 [95% CI: 94, 99]), respectively. Among 190 CEM studies with enhancing findings, enhancing lesions were more likely to be malignant when associated with low-energy findings (26% vs 59%, P < .001). Among enhancement types, mass enhancement composed 71% (99 of 140) of all malignancies with PPV of 63% when associated with low-energy findings. Foci, non-mass enhancement, and mass enhancement without low-energy findings had PPV of 6%, 24%, and 38%, respectively. Neither background parenchymal enhancement nor density was associated with enhancement type (P = .19 and P = .28, respectively). Conclusion Mass enhancement on recombined images using CEM was most commonly associated with malignancy, especially when associated with low-energy findings. Enhancement types were more likely to be benign when not associated with low-energy findings; however, they should still be viewed with suspicion, given the high association with malignancy. © RSNA, 2022 Online supplemental material is available for this article.

Factors Associated With Background Parenchymal Enhancement on Contrast-Enhanced Mammography.

OBJECTIVE. The purpose of this study was to determine the relationship between background parenchymal enhancement (BPE) on contrast-enhanced mammography (CEM) and breast tissue density, menstrual status, endocrine therapy, and risk factors for breast cancer and also to evaluate interreader agreement on classification of BPE on CEM. MATERIALS AND METHODS. Five subspecialty-trained breast radiologists independently and blindly graded tissue density (with fatty tissue and scattered fibroglandular tissue classified as nondense tissue and with heterogeneously dense and extremely dense classified as dense tissue) and BPE (with minimal or mild BPE categorized as low BPE and moderate or marked BPE categorized as high BPE) on CEM examinations performed from 2014 to 2018. Electronic medical charts were reviewed for information on menstrual status, endocrine therapy, history of breast surgery, and other risk factors for breast cancer. Comparisons were performed using the Kruskal-Wallis test, Mann-Whitney test, and Spearman rank correlation. Interreader agreement was estimated using the Fleiss kappa test. RESULTS. A total of 202 patients (mean [± SD] age, 54 ± 10 years; range, 25-84 years) underwent CEM. Tissue density was categorized as fatty in two patients (1%), scattered fibroglandular in 67 patients (33%), heterogeneously dense in 117 patients (58%), and extremely dense in 16 patients (8%). Among the 202 patients, BPE was minimal in 77 (38%), mild in 80 (40%), moderate in 31 (15%), and marked in 14 (7%). Dense breasts, younger age, premenopausal status, no history of endocrine therapy, and no history of breast cancer were significantly associated with high BPE. Among premenopausal patients, no association was found between BPE and time from last menstrual period to CEM. Overall interreader agreement on BPE was moderate (κ = 0.41; 95% CI, 0.40-0.42). Interreader agreement on tissue density was substantial (κ = 0.67; 95% CI, 0.66-0.69). CONCLUSION. Women with dense breasts, premenopausal status, and younger age are more likely to have greater BPE. Targeting CEM to the last menstrual period is not indicated.

Contrast-Enhanced Mammography: A Systematic Guide to Interpretation and Reporting.

OBJECTIVE: The purpose of this article is to discuss the essential steps involved in performing, interpreting, managing, and reporting findings on contrast-enhanced mammography for successful implementation into clinical practice. CONCLUSION: To successfully implement contrast-enhanced mammography into clinical practice, an understanding about the acquisition of images, image interpretation, and reporting of the spectrum of negative, benign, and malignant findings is essential.

Contrast-enhanced Mammography: Current Applications and Future Directions.

Contrast-enhanced mammography (CEM) is a developing modality used for the workup and management of breast cancer. Although diagnostic imaging modalities such as mammography and US have historically been the mainstays of initial breast cancer workup, recent advances in breast MRI have allowed better disease evaluation. However, MRI is not always readily available, can be time consuming, and is contraindicated in certain patients. CEM is an alternative to US and MRI, and it can be used to obtain contrast material-enhanced information and standard mammograms simultaneously. A CEM examination is shorter than that of MRI, and the modalities have similar rates of sensitivity to detect lesions. CEM also costs less than MRI. The authors evaluate clinical uses of CEM and discuss the literature supporting these indications.©RSNA, 2019.

Imaging Findings in Transgender Patients after Gender-affirming Surgery.

Gender-affirming surgeries expand the options for physical transition among transgender patients, those whose gender identity is incongruent with the sex assigned to them at birth. Growing medical insight, increasing public acceptance, and expanding insurance coverage have improved the access to and increased the demand for gender-affirming surgeries in the United States. Procedures for transgender women, those patients with feminine gender identity, include breast augmentation using implants and genital reconstruction with vaginoplasty. Some transgender women receive medically unapproved silicone injections for breast augmentation or other soft-tissue contouring procedures that can lead to disfigurement, silicone pulmonary embolism, systemic reactions, and even death. MRI is preferred over CT for postvaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men, patients with a masculine gender identity, include chest masculinization (mastectomy) and genital reconstruction (phalloplasty or metoidioplasty, scrotoplasty, and erectile device implantation). Urethrography is the standard imaging modality performed to evaluate neourethral patency and other complications, such as leaks and fistulas. Despite a sizeable growth in the surgical literature about gender-affirming surgeries and their outcomes, detailed descriptions of the imaging features following these surgeries remain sparse. Radiologists must be aware of the wide variety of anatomic and pathologic changes unique to patients who undergo gender-affirming surgeries to ensure accurate imaging interpretation. Online supplemental material is available for this article. ©RSNA, 2019.

Breast MRI ordering practices in a large health care network.

The purpose of this study was to evaluate providers' ordering practices and perceptions of breast magnetic resonance imaging (MRI) in an academic network in order to better understand and educate a referral base. An online survey was distributed to primary care providers (PCPs) and specialists in our hospital and community practices. Questions included provider demographics, current ordering practices, challenges to ordering, and perceptions about breast MRI. Of 525 ordering providers, 134 responded (26% response rate). Of 134 providers, 57 (42%) order breast MRI in practice. Of those who do not, the most consistent reason was a lack of familiarity with the use of breast MRI (32/77 [42%] of cases). Of 57 cases, 45 (79%) order less than 10 exams annually. The most frequent indication is for high-risk screening (40/47 [84%]). PCPs order fewer breast MRI compared with specialists (P = 0.01). Both PCPs and specialists have mixed perceptions of the clinical utility of breast MRI. However, 30% of all providers are ordering more breast MRI since the enactment of breast density legislation in Massachusetts. Furthermore, 29% report they would order breast MRI more often to screen women with dense breasts if there was a low cost option. Referring provider surveys are useful tools for assessing a radiology practice. Our study suggests a growing clinical interest in breast MRI for screening; however, there is a need for provider education on the clinical utility of breast MRI. Increasing the radiologist's role in targeted educational interventions may help improve awareness and lead to more appropriate utilization of resources.

Potential role of abbreviated MRI for breast cancer screening in an academic medical center.

The purpose is to determine whether an abbreviated MRI protocol (ABMR) is ready to be used for breast cancer screening in an academic practice setting. Two hundred and fifty nine breast MRIs from 1/1/2012 to 6/30/2012 were retrospectively reviewed using ABMR (MIP, Pre-contrastT1, single dynamic post-contrastT1, and subtraction). Five breast radiologists (4-28 year-expr) participated in this reader study performed in two phases: Phase1 - radiologist's privy to clinical history but not to comparison imaging. Phase2 - radiologists provided comparison imaging. For phase1, studies were reviewed using three steps: (a) MIP only (positive/negative/intermediate); (b) ABMR (recall/no recall) and (c) With T2 (for changes in recommendations). Radiologist also recorded total time for interpretation. In Phase2 the MRIs coded as "recall" were re-reviewed with available comparison studies, noting changes in final recommendation. The abnormal interpretation rates (AIRs) were calculated for phase1 and phase2 results with comparison to the original full protocol. Of the 259 patients (avg. age-52 years; range 26-78), there were seven cancers (three invasive, three DCIS and one breast lymphoma). Acquisition time for ABMR was 3 minutes, ABMR + T2-8 minutes, and original full protocol 16 minutes. Average MIP was positive or indeterminate in 86% (6/7) and negative in 14% (1/7) cancers. The average AIR for MIP only was 20.8% (sens-77.1%; spec-80.8%. The AIR w/o comparisons was 25.6% (sens-91.4%; spec- 76.2%); however the average AIR decreased in phase 2 with comparisons to 13.7% (sens-91.4%; spec-88.5%). The AIR of the original full protocol read was 16.2% (sens-100%; spec-85.7%). Addition of T2 changed assessment in only 3% (1.2%-6.5%). Avg. read time for ABMR including T2 was 2.5 minutes (1.6-4.0 minutes). ABMR is reliable for breast cancer screening, with acceptable interpretation time and acceptable AIR.

Comparative Dose of Contrast-Enhanced Spectral Mammography (CESM), Digital Mammography, and Digital Breast Tomosynthesis.

OBJECTIVE: The purpose of this study is to provide a more accurate estimation of the radiation dose of contrast-enhanced spectral mammography (CESM) relative to that of 2D digital mammography and tomosynthesis using phantom and patient data and an accepted dosimetry protocol that eliminates vendor-specific average glandular dose (AGD) estimates while including breast density. MATERIALS AND METHODS: Patient and phantom AGD estimation was performed using two vendors (system 1 and system 2) in five imaging modes, including 2D, 3D, and CESM imaging. Patient AGD was retrospectively estimated from 45 patients who underwent mammography with all imaging modes during 2012-2016. Patient and phantom AGD were estimated using accepted European and International Atomic Energy Agency protocols for dosimetry and were compared across imaging modes using a paired t test with Bonferroni correction. RESULTS: Phantom data showed that the imaging modes with the lowest to highest AGDs were system 1 2D, followed by system 2 2D and system 2 3D, which had comparable values (p = 0.6), followed by system 1 CESM, and then by system 2 2D plus 3D. One hundred eighty views in 45 patients showed that the system 1 CESM AGD was 1.8 times greater than the system 1 2D AGD (p < 0.001), 1.2 times greater than the system 2 2D AGD (p < 0.001), 1.2 times greater than the system 2 3D AGD (p < 0.001), and 0.6 times less than the system 2 2D plus 3D AGD (p < 0.001). CONCLUSION: The CESM dose for system 1 is within an acceptable range as compared with other commonly performed mammographic examinations and should not preclude its use as a diagnostic breast imaging tool.

Clinical Value of Mammography in the Evaluation of Palpable Breast Lumps in Women 30 Years Old and Older.

OBJECTIVE: The purpose of this study was to determine whether mammography adds clinical value in the diagnostic imaging workup of women 30 years old and older who present with palpable breast lumps. MATERIALS AND METHODS: We retrospectively identified the records of all women 30 years old and older who underwent imaging evaluation with mammography and ultrasound for a palpable lump between January 1, 2009, and December 31, 2010. Imaging reports were reviewed for findings related to the lump and for incidental nonpalpable findings. Benign versus malignant outcomes were determined by pathologic analysis or 24-month imaging or clinical follow-up. The contribution of mammography to final diagnosis was assessed on the basis of objective criteria to determine the clinical impact of mammographic findings. RESULTS: The study cohort included 861 patients presenting with 935 palpable lumps. Imaging correlates were reported for 568 of 935 (60.7%) lumps, and imaging findings were negative in 367 of 935 (39.3%). Of the 935 palpable lumps, 858 (91.8%) were benign and 77 (8.2%) were malignant. Mammography added clinical value in the evaluation of 27 of 77 (35.0%) malignant lumps by better delineating extent of disease and in the evaluation of 26 of 858 benign lumps (3.0%) by confirming benignity. Fifty-two of 861 (6.0%) patients had incidental findings that led to a recommendation for biopsy. Twenty-nine of the 52 findings were originally seen with mammography and 23 with ultrasound. Mammography also depicted seven incidental malignancies in nonpalpable areas, and ultrasound depicted one incidental malignancy. CONCLUSION: Adjunct mammography is warranted for evaluation of palpable breast lumps in women 30 years old and older because of the value added to clinical management. In all age cohorts, mammography contributed to delineation of disease extent, detection of incidental malignancies, and confirmation of benign diagnoses.

Prediction of Low versus High Recurrence Scores in Estrogen Receptor-Positive, Lymph Node-Negative Invasive Breast Cancer on the Basis of Radiologic-Pathologic Features: Comparison with Oncotype DX Test Recurrence Scores.

Purpose To review mammographic, ultrasonographic (US), and magnetic resonance (MR) imaging features and pathologic characteristics of estrogen receptor (ER)-positive, lymph node-negative invasive breast cancer and to determine the relationship of these characteristics to Oncotype DX (Genomic Health, Redwood City, Calif) test recurrence scores (ODRS) for breast cancer recurrence. Materials and Methods This institutional review board-approved retrospective study was performed in a single large academic medical center. The study population included patients with ER-positive, lymph node-negative invasive breast cancer who underwent genomic testing from January 1, 2009, to December 31, 2013. Imaging features of the tumor were classified according to the Breast Imaging Reporting and Data System lexicon by breast imagers who were blinded to the ODRS. Mammography was performed in 86% of patients, US was performed in 84%, and MR imaging was performed in 33%, including morphologic and kinetic evaluation. Images from each imaging modality were evaluated. Each imaging finding, progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status, and tumor grade were then individually correlated with ODRS. Analysis of variance was used to determine differences for each imaging feature. Regression analysis was used to calculate prediction of recurrence on the basis of imaging features combined with histopathologic features. Results The 319 patients had a mean age ± standard deviation of 55 years ± 8.7 (range, 31-82 years). Imaging features with a positive correlation with ODRS included a well-circumscribed oval mass (P = .024) at mammography, vascularity (P = .047) and posterior enhancement (P = .004) at US, and lobulated mass (P = .002) at MR imaging. Recurrence scores were predicted by using these features in combination with PR and HER2 status and tumor grade by using the threshold of more than 30 as a high recurrence score. With a regression tree, there was correlation (r = 0.79) with 89% sensitivity and 83% specificity. Conclusion On the basis of preliminary data, information obtained routinely for breast cancer diagnosis can reliably be used to predict the ODRS with high sensitivity and specificity. (©) RSNA, 2016.

Increased Cancer Detection Rate and Variations in the Recall Rate Resulting from Implementation of 3D Digital Breast Tomosynthesis into a Population-based Screening Program.

PURPOSE: To compare the recall and cancer detection rates (CDRs) at screening with digital breast tomosynthesis (DBT) with those at screening with two-dimensional (2D) mammography and to evaluate variations in the recall rate (RR) according to patient age, risk factors, and breast density and among individual radiologists at a single U.S. academic medical center. MATERIALS AND METHODS: This institutional review board-approved, HIPAA-compliant prospective study with a retrospective cohort included 85 852 asymptomatic women who presented for breast cancer screening over a 3-year period beginning in 2011. A DBT unit was introduced into the existing 2D mammography screening program, and patients were assigned to the first available machine. Ten breast-subspecialized radiologists interpreted approximately 90% of the examinations. RRs were calculated overall and according to patient age, breast density, and individual radiologist. CDRs were calculated. Single and multiple mixed-effect logistic regression analyses, χ(2) tests, and Bonferroni correction were utilized, as appropriate. RESULTS: The study included 5703 (6.6%) DBT examinations and 80 149 (93.4%) 2D mammography examinations. The DBT subgroup contained a higher proportion of patients with risk factors for breast cancer and baseline examinations. DBT was used to detect 54.3% more carcinomas (+1.9 per 1000, P < .0018) than 2D mammography. The RR was 7.51% for 2D mammography and 6.10% for DBT (absolute change, 1.41%; relative change, -18.8%; P < .0001). The DBT subgroup demonstrated a significantly lower RR for patients with extremely or heterogeneously dense breasts and for patients in their 5th and 7th decades. CONCLUSION: Implementing DBT into a U.S. breast cancer screening program significantly decreased the screening RR overall and for certain patient subgroups, while significantly increasing the CDR. These findings may encourage more widespread adoption and reimbursement of DBT and facilitate improved patient selection.

Breast imaging in the transgender patient.

OBJECTIVE: Limited information exists regarding breast health in the transgender population. In this article, we review transgender terminology, barriers faced by transgender patients, current breast care screening recommendations, and normal and abnormal imaging findings in this population. CONCLUSION: Health disparities in the transgender population continue. Educating physicians on the breast health care needs of transgender patients is important for improving their care.

Impact of imaging nurse navigation on breast interventions: Direct and closed-loop patient communication and documentation.

OBJECTIVE: A breast imaging nurse navigator (NN) was established with the goals to enhance the patient experience after biopsy, improve care timeliness, accuracy, and coordination, facilitate direct communication to patients, and increase care retention within our system. Our aim was to determine the impact of NN on patient care time metrics, communication, documentation, compliance, and care retention at our institution after breast biopsy. METHODS: Retrospective review of a six-month period before (5/1/17-10/31/17) and after (5/1/19-10/31/19) establishment of a nurse navigator in our breast imaging department was performed, including 498 patients in the pre-navigation (pre-NN) group and 526 patients in the post-navigation (post-NN) group. Data was gathered from the electronic medical record and collected using REDCap. RESULTS: Biopsy pathology results were communicated directly to the patient more often post-NN (71%, 374/526) compared to pre-NN (4%, 21/498) (p < 0.0001), without change in overall time of result communication (p = 0.08). Due to factors outside of imaging, most care time metrics were longer post-NN, including days from biopsy to pathology report (p < 0.001), result communication to initiation of care (p < 0.001), and biopsy to surgery (p < 0.001). There was no difference and high compliance (p = 1) and care retention (p = 0.015) in both groups. There was improved documentation of pathology results, recommendations, and communication post-NN (0/526 vs 10/498, p = 0.001). CONCLUSION: Imaging nurse navigation added greatest value by communicating breast biopsy results and recommendations directly to patients and ensuring documentation. Compliance and retention were high in both groups. Factors outside of Radiology influenced time metrics, requiring further investigation of multidisciplinary collaboration.

Prospective Evaluation of the Cost of Performing Breast Imaging Examinations Using a Time-Driven Activity-Based Costing Method: A Single-Center Study.

OBJECTIVE: Measuring the cost of performing breast imaging is difficult in healthcare systems. The purpose of our study was to evaluate this cost using time-driven activity-based costing (TDABC) and to evaluate cost drivers for different exams. METHODS: An IRB-approved, single-center prospective study was performed on 80 female patients presenting for breast screening, diagnostic or biopsy exams from July 2020 to April 2021. Using TDABC, data were collected for each exam type. Included were full-field digital mammography (FFDM), digital breast tomosynthesis (DBT), contrast-enhanced mammography (CEM), US and MRI exams, and stereotactic, US-guided and MRI-guided biopsies. For each exam type, mean cost and relative contributions of equipment, personnel and supplies were calculated. RESULTS: Screening MRI, CEM, US, DBT, and FFDM costs were $249, $120, $83, $28, and $30. Personnel was the major contributor to cost (60.0%-87.0%) for all screening exams except MRI where equipment was the major contributor (62.2%). Diagnostic MRI, CEM, US, and FFDM costs were $241, $123, $70, and $43. Personnel was the major contributor to cost (60.5%-88.6%) for all diagnostic exams except MRI where equipment was the major contributor (61.8%). Costs of MRI-guided, stereotactic and US-guided biopsy were $1611, $826, and $356. Supplies contributed 40.5%-49.8% and personnel contributed 30.7%-55.6% to the total cost of biopsies. CONCLUSION: TDABC provides assessment of actual costs of performing breast imaging. Costs and contributors varied across screening, diagnostic and biopsy exams and modalities. Practices may consider this methodology in understanding costs and making changes directed at cost savings.

Breast Imaging Fellowship Training in the United States: A National Survey of Fellowship Program Directors.

OBJECTIVE: To provide an updated characterization of breast imaging fellowship programs in the United States to identify opportunities for improvement and standardization. METHODS: An anonymous survey was e-mailed to program directors of breast imaging fellowship programs listed on the Society of Breast Imaging website. The survey was open from April 23, 2021, through May 27, 2021. The survey was deemed exempt by the IRB. RESULTS: Forty-seven of 80 (59%) program directors responded, of which 36/47 (77%) represented programs dedicated 100% to breast imaging, and 11/47 (23%) represented programs dedicated 50%-75% to breast imaging. Common elements to most programs include tumor boards (47/47, 100%), journal clubs (39/47, 83%), case-based teaching sessions (35/47, 74%), didactic lectures (40/47, 85%), and participation in radiology-pathology conferences (29/47, 62%). Mammography Quality and Standards Act audit training (22/47, 47%), mammography quality control training (22/47, 47%), and formal communication training (19/47, 40%) were less common. Most programs provide exposure to wire (42/47, 89%) and wire-free localization procedures (45/47, 96%), but exposure to contrast-enhanced mammography (13/47, 28%) and molecular breast imaging (4/47, 9%) was limited. A small majority of programs (25/47, 53%) do not require weekday call; however, more (31/47, 66%) have weekend call responsibilities. Many programs (29/47, 62%) offer at least 3 weeks of elective time, which may be clinical or nonclinical. CONCLUSION: Breast imaging fellowship programs vary in curricula, modality exposure, and academic policies. The results of this survey can help guide further efforts to standardize and optimize fellowship training.

Imaging Preferences in Women With a History of Breast Cancer Receiving Contrast-Enhanced Mammography.

OBJECTIVE: There is interest in contrast-enhanced mammography (CEM) to screen breast cancer survivors, yet it is unclear whether they would accept CEM as their annual exam. The purpose of this study was to understand patient preferences to guide CEM implementation for screening. METHODS: Consecutive women with breast cancer history who had CEM as their annual mammogram from July 2020 to August 2021 at a single academic institution completed an 18-question survey regarding prior contrast imaging, CEM experience, and comparison to other breast imaging exams. Response proportions were calculated, and chi-square or Fisher's exact test were used to evaluate associations of demographics with responses. RESULTS: A total of 78% (104/133) of women undergoing CEM provided results. Most were satisfied with CEM (99%, 103/104), had nothing to complain about (87%, 90/104), did not find CEM anxiety provoking (69%, 72/104), felt comfortable having contrast for annual imaging (94%, 98/104), were willing to accept the small risk of a contrast reaction if CEM would find their cancer (93%, 97/104), and would like to have CEM for their exam next year (95%, 99/104). Compared with mammography, 23% (24/104) reported CEM was a better experience, and 63% (66/104) reported CEM was about the same. Of those who had prior MRI, the majority reported CEM was better (53%, 29/55) and would prefer CEM if both MRI and CEM had an equal chance of detecting cancer (73%, 41/56). Most preferences did not differ significantly according to demographics. CONCLUSION: Most women surveyed considered CEM to be satisfactory and preferred compared to other breast screening modalities.

Management of Mammographic Architectural Distortion Based on Contrast-enhanced MRI and US Correlation.

OBJECTIVE: The objective was to evaluate outcomes of mammographic architectural distortion (AD) with and without MRI and US correlates. METHODS: A retrospective review of unexplained mammographic AD with subsequent MRI from January 1, 2007 to September 30, 2017 was performed using a reader-based study design. Mammographic, MRI, and US features and outcomes were documented. Truth was based on biopsy results or minimum two-year imaging follow-up. Measures of diagnostic accuracy were calculated. RESULTS: Fifty-six cases of AD were included: 29 (51.8%) detected on 2D mammogram and 27 (48.2%) detected on digital breast tomosynthesis. Of 35.7% (20/56) with MRI correlate, 40.0% (8/20) were enhancing masses, 55.0% (11/20) were non-mass enhancement (NME), and 5.0% (1/20) were nonenhancing AD. Of eight enhancing masses, 75.0% (6/8) were invasive cancers, and 25.0% (2/8) were high-risk lesions. Of 11 NME, 18.2% (2/11) were ductal carcinoma in situ, 36.4% (4/11) were high-risk lesions, and 45.4% (5/11) were benign. Of 64.3% (36/56) without MRI correlate, 94.4% (34/36) were benign by pathology or follow-up, one (2.8%, 1/36) was a 4-mm focus of invasive cancer with US correlate, and one (1/36, 2.8%) was a high-risk lesion. Of cases without MRI and US correlates, one (3.0%, 1/33) was a high-risk lesion and 97.0% (32/33) were benign. The negative predictive value of mammographic AD without MRI correlate was 97.2% (35/36) and without both MRI and US correlates was 100.0% (33/33). CONCLUSION: Mammographic AD without MRI or US correlate was not cancer in our small cohort and follow-up could be considered, reducing interventions.