Examination of fully automated mammographic density measures using LIBRA and breast cancer risk in a cohort of 21,000 non-Hispanic white women.

BACKGROUND: Breast density is strongly associated with breast cancer risk. Fully automated quantitative density assessment methods have recently been developed that could facilitate large-scale studies, although data on associations with long-term breast cancer risk are limited. We examined LIBRA assessments and breast cancer risk and compared results to prior assessments using Cumulus, an established computer-assisted method requiring manual thresholding. METHODS: We conducted a cohort study among 21,150 non-Hispanic white female participants of the Research Program in Genes, Environment and Health of Kaiser Permanente Northern California who were 40-74 years at enrollment, followed for up to 10 years, and had archived processed screening mammograms acquired on Hologic or General Electric full-field digital mammography (FFDM) machines and prior Cumulus density assessments available for analysis. Dense area (DA), non-dense area (NDA), and percent density (PD) were assessed using LIBRA software. Cox regression was used to estimate hazard ratios (HRs) for breast cancer associated with DA, NDA and PD modeled continuously in standard deviation (SD) increments, adjusting for age, mammogram year, body mass index, parity, first-degree family history of breast cancer, and menopausal hormone use. We also examined differences by machine type and breast view. RESULTS: The adjusted HRs for breast cancer associated with each SD increment of DA, NDA and PD were 1.36 (95% confidence interval, 1.18-1.57), 0.85 (0.77-0.93) and 1.44 (1.26-1.66) for LIBRA and 1.44 (1.33-1.55), 0.81 (0.74-0.89) and 1.54 (1.34-1.77) for Cumulus, respectively. LIBRA results were generally similar by machine type and breast view, although associations were strongest for Hologic machines and mediolateral oblique views. Results were also similar during the first 2 years, 2-5 years and 5-10 years after the baseline mammogram. CONCLUSION: Associations with breast cancer risk were generally similar for LIBRA and Cumulus density measures and were sustained for up to 10 years. These findings support the suitability of fully automated LIBRA assessments on processed FFDM images for large-scale research on breast density and cancer risk.

Optimizing the Patient Experience in Breast Imaging Facilities: AJR Expert Panel Narrative Review.

Breast imaging studies are complex examinations for patients and providers. Breast imaging providers and organizations invest significant resources in educating patients and referring providers to address variability in changing breast cancer screening recommendations, cultural biases, and socioeconomic barriers for patients. The breast imaging examination frequently involves multiple imaging modalities including interventional procedures, thus requiring multiple room types. Practices need to consider variables that affect workflow efficiency throughout the process of scheduling, examination performance, interpretation, and results delivery, as well as options in facilities design to create inviting yet functional environments for patients. Breast imaging appointments provide opportunity to capture individual breast cancer risk and to engage patients in health education and breast screening awareness. This AJR Expert Panel Narrative Review discusses ways in which breast imaging facilities can optimize patient experience throughout the complex process of a breast imaging examination, based on the authors' observations and opinions that include private and academic breast imaging experience.

Impact of Screening Mammography on Treatment in Young Women Diagnosed with Breast Cancer.

BACKGROUND: There is little data exploring the impact of screening mammography on subsequent treatment in the 40-49-year age group with breast cancer. We sought to assess the association between frequency of mammography in young women and extent of surgery and chemotherapy required. METHODS: An IRB-approved retrospective review was performed of patients diagnosed with breast cancer between ages 40 and 49 years from 1 January 2010 to 19 November 2018 within a single health system. Patients were grouped based on last screening 1-24 months prior to diagnosis (1-24 group), > 25 months prior to diagnosis (> 25 group), never screened, and > 25+ never screened (combination group). Multivariate logistic regression models were used to assess for associations between screening intervals and tumor and nodal stage, chemotherapy use, and extent of surgery. RESULTS: Of 869 patients included for analysis, 20% were never screened, 60% screened 1-24 months, and 19% screened > 25 months prior to diagnosis. Compared with the 1-24 months group, the never-screened group, > 25 months group, and combined group were more likely to receive chemotherapy. The never-screened and combined groups were more likely to undergo mastectomy and/or axillary lymph node dissection. Of patients undergoing upfront surgery, the > 25 months and combined groups were more likely to receive adjuvant chemotherapy, while the never-screened and combined groups were more likely to have nodal disease. CONCLUSION: Our findings support the initiation of screening mammography at age 40 years to reduce the risk of aggressive treatments for newly diagnosed breast cancers in this group.

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients.

BACKGROUND: Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics. OBJECTIVES: To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics. DESIGN: Electronic medical record review of abnormal screening mammograms. SUBJECTS: Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337). MAIN MEASURES: Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors. KEY RESULTS: Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively. CONCLUSIONS: A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

Screening Mammogram Adherence in Medically Underserved Women: Does Language Preference Matter?

This study examines the relationship between language preference and screening mammogram adherence in medically underserved women in New York City. A survey was conducted with 518 women age 40 and over attending breast health education programs in English, Spanish, Chinese (Mandarin/Cantonese), and French. Women who preferred Chinese were 53% less likely to have had a mammogram within the past year compared to women who preferred English (p < .01). Women age 75 and older (p < .0001) and those without insurance (p < .05) were also found to be significantly less likely to have had a screening mammogram compared to women ages 55-74 and those with private insurance, respectively. This research indicates medically underserved women who prefer a non-English language may benefit from linguistically appropriate interventions to improve screening mammogram adherence. Future research should examine appropriateness of breast cancer screening for women age 75 and older and explore ways to improve screening mammogram use in the uninsured population.

Developing a Culturally and Linguistically Targeted Breast Cancer Educational Program for a Multicultural Population.

Breast cancer is the most commonly diagnosed cancer among women in the USA. Despite the availability of screening mammograms, significant disparities still exist in breast cancer outcomes of racial/ethnic and sexual/gender minorities. To address these disparities, the Mount Sinai Mobile Breast Health Program in New York City collaborated with local organizations to develop culturally and linguistically appropriate breast cancer education programs aimed at increasing screening mammogram utilization. Literature review of the barriers to mammography screening formed the basis to allow us to draft a narrative presentation for each targeted cultural group: African American, African-born, Chinese, Latina, and Muslim women, as well as LGBTQ individuals. The presentations were then tested with focus groups comprised of gatekeepers and members from local community and faith-based organizations which served the targeted populations. Feedback from focus groups and gatekeepers was incorporated into the presentations, and if necessary, the presentations were translated. Subsequently, the presentations were re-tested for appropriateness and reviewed for consistency in message, design, educational information, and slide sequencing. Our experience demonstrated the importance of collaborating with community organizations to provide educational content that is culturally and linguistically appropriate for minority groups facing barriers to uptake of screening mammography.

Racial/ethnic differences in supplemental imaging for breast cancer screening in women with dense breasts.

BACKGROUND: Mammography is limited when analyzing dense breasts for 2 reasons: (1) breast density masks underlying cancers and (2) breast density is an independent risk factor for cancer. We undertook this study to assess whether there is a racial/ethnic difference in supplemental image ordering for women with dense breasts. METHODS: We conducted a retrospective, observational cohort study of women aged 50-75 from an academic medical center who had completed a screening mammogram between 2014 and 2016 that was read as BI-RADS 1 with heterogeneously or extremely dense breasts or BI-RADS 2 with extremely dense breasts. Data were abstracted on type, timing and frequency of supplemental imaging tests ordered within two years of an initial screening mammogram. Patient characteristics (age, race/ethnicity, insurance, and comorbidities) were also abstracted. We used bivariate and multivariate logistic regression to assess for differences in supplemental imaging ordered by race/ethnicity. RESULTS: Three hundred twenty-six women met inclusion criteria. Mean age was 58 years: 25% were non-Hispanic white, 30% were non-Hispanic black, 27% were Hispanic, 6% were Asian and 14% unknown. Seventy-nine (24%) women were ordered a supplemental breast ultrasound after the initial screening mammogram. Non-Hispanic black and Hispanic women were less likely to have supplemental imaging ordered compared to non-Hispanic white women (15% and 10%, respectively, vs. 45%, p < 0.0001). After controlling for patient age, ordering physician specialty, insurance, BI-RADS score, breast density, and family history of breast cancer, non-Hispanic black and Hispanic women remained less likely to be ordered supplemental imaging (OR 0.38 [95% CI 0.17-0.85] and OR 0.24 [95% CI 0.10-0.61], respectively, p < 0.0001). CONCLUSION: Minority women with dense breasts are less likely to be ordered supplemental breast imaging. Further research should investigate physician and patient behaviors to determine barriers in supplemental imaging. Understanding these differences may help reduce disparities in breast cancer care and mortality.

Breast Arterial Calcification in the Mammogram Report: The Patient Perspective.

OBJECTIVE: The purpose of this study was to determine patient attitudes about mammographic reporting of breast arterial calcification (BAC), result communication, and action. SUBJECTS AND METHODS: A self-administered survey was created for this project and was offered to mammography patients presenting for screening or diagnostic mammography over a 1-month period. RESULTS: Among those who accepted questionnaires, 61.8% (419/678) responded with varying response rates to specific questions. A large percentage (95.8% [363/379]) preferred to have BAC reported. All 107 patients who were unaware of a personal history of heart disease wanted notification about BAC. There were 552 communication responses from 354 women. Among these responses, 62.5% (345/552) indicated a preference for notification from the radiology department by letter or telephone call. Among those who had a single preference, 76.6% (180/235) preferred notification by the radiology department in the patient results letter or by telephone call. Of those who chose one action option, 87.4% (181/207) indicated that they would undergo coronary artery CT before making a decision. Among those who selected multiple options, 53.2% (272/511) expressed a desire for coronary artery CT before making a decision. Age, level of education, and race were not associated with patients' attitudes toward BAC. CONCLUSION: Patients had an overwhelming preference to be informed about BAC found at mammography. Given the ease of reporting BAC and the calls by preventive cardiologists to have the information, the widespread adoption of BAC reporting on mammography reports can promote prevention, diagnosis, and if needed, treatment of cardiovascular disease.

Observation versus excision of lobular neoplasia on core needle biopsy of the breast.

PURPOSE: Controversy surrounds management of lobular neoplasia (LN), [atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS)], diagnosed on core needle biopsy (CNB). Retrospective series of pure ALH and LCIS reported "upgrade" rate to DCIS or invasive cancer in 0-40%. Few reports document radiologic/pathologic correlation to exclude cases of discordance that are the likely source of most upgrades, and there is minimal data on outcomes with follow-up imaging and clinical surveillance. METHODS: Cases of LN alone on CNB (2001-2014) were reviewed. CNB yielding LN with other pathologic findings for which surgery was indicated were excluded. All patients had either surgical excision or clinical follow-up with breast imaging. All cases included were subject to radiologic-pathologic correlation after biopsy. RESULTS: 178 cases were identified out of 62213 (0.3%). 115 (65%) patients underwent surgery, and 54 (30%) patients had surveillance for > 12 months (mean = 55 months). Of the patients who underwent surgical excision, 13/115 (11%) were malignant. Eight of these 13 found malignancy at excision when CNB results were considered discordant (5 DCIS, and 3 invasive lobular carcinoma), with the remainder, 5/115 (4%), having a true pathologic upgrade: 3 DCIS, and 2 microinvasive lobular carcinoma. Among 54 patients not having excision, 12/54 (22%) underwent subsequent CNB with only 1 carcinoma found at the initial biopsy site. CONCLUSIONS: Surgical excision of LN yields a low upgrade rate when careful consideration is given to radiologic/pathologic correlation to exclude cases of discordance. Observation with interval breast imaging is a reasonable alternative for most cases.

Impact of Screening Mammography on Treatment in Women Diagnosed with Breast Cancer.

BACKGROUND: Screening mammography reduces breast cancer mortality; however, screening recommendations, ordering, and compliance remain suboptimal and controversies regarding the value of screening persist. We evaluated the influence of screening mammography on the extent of breast cancer treatment. METHODS: Patients ≥ 40 years of age diagnosed with breast cancer from September 2008 to May 2016 at a single institution were divided into two groups: those with screening 1-24 months prior to diagnosis, and those with screening at 25+ months, including patients with no prior mammography. The association between the two groups and various clinical factors were assessed using logistic regression models. Subgroup analysis was performed based on age groups. RESULTS: Analysis included 1125 patients, 819 (73%) with screening at 1-24 months, and 306 (27%) with screening at 25+ months, including 65 (6%) who never had mammography. Overall, patients in the 25+ months group were more likely to receive chemotherapy [odds ratio (OR) 1.51, p = 0.0040], undergo mastectomy (OR 1.32, p = 0.0465), and require axillary dissection (AD; OR 1.66, p = 0.0045) than those in 1-24 months group. On subgroup analysis, patients aged 40-49 years with no prior mammography were more likely to have larger tumors (p = 0.0323) and positive nodes (OR 4.52, p = 0.0058), undergo mastectomy (OR 3.44, p = 0.0068), undergo AD (OR 4.64, p = 0.0002), and require chemotherapy (OR 2.52, p = 0.0287) than the 1-24 months group. CONCLUSIONS: Screening mammography is associated with decreased stage at diagnosis and receipt of less-extensive treatment. This was evident in all groups, including the 40-49 years age group, where controversy exists on whether screening is even necessary.

Mobile Mammography Participation Among Medically Underserved Women: A Systematic Review.

INTRODUCTION: Although breast cancer deaths have declined, the mortality rate among women from medically underserved communities is disproportionally high. Screening mammography is the most effective tool for detecting breast cancer in its early stages, yet many women from medically underserved communities do not have adequate access to screening mammograms. Mobile mammography may be able to bridge this gap by providing screening mammograms at no cost or low cost and delivering services to women in their own neighborhoods, thus eliminating cost and transportation barriers. The objective of this systematic review was to describe the scope and impact of mobile mammography programs in promoting mammographic screening participation among medically underserved women. METHODS: We searched electronic databases for English-language articles published in the United States from January 2010 through March 2018 by using the terms "mobile health unit," "mammogram," "mammography," and "breast cancer screening." Of the 93 articles initially identified, we screened 55; 16 were eligible to be assessed and 10 qualified for full text review and data extraction. Each study was coded for study purpose, research design, data collection, population targeted, location, sample size, outcomes, predictors, analytical methods, and findings. RESULTS: Of the 10 studies that qualified for review, 4 compared mobile mammography users with users of fixed units, and the other 6 characterized mobile mammography users only. All the mobile mammography units included reached underserved women. Most of the women screened in mobile units were African American or Latina, low income, and/or uninsured. Mobile mammography users reported low adherence to 1-year (12%-34%) and 2-year (40%-48%) screening guidelines. Some difficulties faced by mobile clinics were patient retention, patient follow-up of abnormal or inconclusive findings, and women inaccurately perceiving their breast cancer risk. CONCLUSION: Mobile mammography clinics may be effective at reaching medically underserved women. Adding patient navigation to mobile mammography programs may promote attendance at mobile sites and increase follow-up adherence. Efforts to promote mammographic screening should target women from racial/ethnic minority groups, women from low-income households, and uninsured women. Future research is needed to understand how to best improve visits to mobile mammography clinics.

Variable Appearances of Ductal Carcinoma In Situ Calcifications on Digital Mammography, Synthesized Mammography, and Tomosynthesis: A Pictorial Essay.

This pictorial essay demonstrates the variable appearances of ductal carcinoma in situ on full-field digital mammography, synthesized mammography, and digital breast tomosynthesis. The spectrum of intercase and intracase variability suggests further refinement of reconstruction algorithms for synthesized mammography may be necessary to maximize early detection of ductal carcinoma in situ.

Breast Imaging in the Era of Big Data: Structured Reporting and Data Mining.

OBJECTIVE: The purpose of this article is to describe structured reporting and the development of large databases for use in data mining in breast imaging. CONCLUSION: The results of millions of breast imaging examinations are reported with structured tools based on the BI-RADS lexicon. Much of these data are stored in accessible media. Robust computing power creates great opportunity for data scientists and breast imagers to collaborate to improve breast cancer detection and optimize screening algorithms. Data mining can create knowledge, but the questions asked and their complexity require extremely powerful and agile databases. New data technologies can facilitate outcomes research and precision medicine.

Incremental Role of Mammography in the Evaluation of Gynecomastia in Men Who Have Undergone Chest CT.

OBJECTIVE: The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest. MATERIALS AND METHODS: In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome. RESULTS: Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy. CONCLUSION: The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.

Breast density: comparison of chest CT with mammography.

PURPOSE: To (a) perform a pilot study comparing radiologists' reading of breast density at computed tomography (CT) of the chest with breast density readings from mammography performed in the same patient and (b) compare a subset of these with computer-derived measurements of breast density at CT. MATERIALS AND METHODS: The institutional review board waived informed consent for this HIPAA-compliant retrospective review of mammograms and chest CT scans from 206 women obtained within 1 year of each other. Two radiologists with expertise in interpreting mammographic and CT findings independently reviewed the mammograms and CT scans and classified each case into one of the four breast density types defined by the Breast Imaging Reporting and Data System of the American College of Radiology. Interreader agreements for the mammographic density types and CT density grades were determined by using the Cohen weighted κ statistic. The intrareader correlation coefficient was determined in a subset of CT images. In another subset of 40 cases, the agreement of the semiautomated computer-derived measurements of breast density with the consensus of the two radiologists was assessed. RESULTS: Interreader agreement was higher for the CT density grades than for the mammographic density types, with 0.79 (95% confidence interval [CI]: 0.73, 0.85) versus 0.62 (95% CI: 0.54, 0.70). The intrareader reliability of breast density grades on CT images was 0.88. The computer-derived breast density measurements agreed with those of the radiologists in 36 (90%) cases. When four cases were manually adjusted for the complex anatomy, there was agreement for all cases. CONCLUSION: Preliminary results suggest that on further validation, breast density readings at CT may provide important additional risk information on CT of the chest and that computer-derived measurements may be helpful in such assessment.

Breast cancer in male-to-female transsexuals: use of breast imaging for detection.

OBJECTIVE: The purposes of this article are to describe two cases of breast cancer in male-to-female transsexuals and to review eight cases previously reported in the literature. CONCLUSION: Breast cancer occurs in male-to-female transsexuals who receive high doses of exogenous estrogen and develop breast tissue histologically identical to that of a biologically female breast. This exposure to estrogen results in increased risk of breast cancer. The first patient described is a male-to-female transsexual with screening-detected ductal carcinoma in situ and a family history of breast cancer. The other patient is a male-to-female transsexual with invasive ductal carcinoma that was occult on diagnostic digital mammographic and ultrasound findings but visualized on digital breast tomosynthesis and breast MR images. The analysis of the eight previously reported cases showed that breast cancer in male-to-female transsexuals occurs at a younger age and is more frequently estrogen receptor negative than breast cancer in others born biologically male. Screening for breast cancer in male-to-female transsexuals should be undertaken for those with additional risk factors (e.g., family history, BRCA2 mutation, Klinefelter syndrome) and should be available to those who desire screening, preferably in a clinical trial.

Early discussion of breast density and supplemental breast cancer screening: is it possible?

The purpose of this study is to determine whether it is possible to make breast cancer screening more efficient in those with dense breasts. Over 12 states require that patients with dense breasts receive notification about their breast density in lay letters that are sent after the screening mammogram. Some of these letters advise patients to speak with their primary care providers about the possibility of supplemental breast cancer screening. We sought to determine whether primary care providers can discuss breast density and recommend supplemental breast cancer screening using the density of the previous mammography. This would reduce the burden of additional appointments and might increase the number of patients choosing to have supplemental screening. The mammographic breast density of 250 consecutive patients from May 2011 to September 2011 was compared with the immediate prior mammogram. Patients whose prior mammograms were more than 36 months prior or less than 8 months prior to the current exam were excluded, leaving 217 patients. The proportion of patients with breast density change was analyzed. The concordance of breast density between the two exams was assessed and the effects of patient age and the length of time between mammograms were examined. The breast density of the current and most recent prior mammogram was stable for 86.6% of patients. Neither age nor length of time between mammograms affected concordance. Primary care providers can decrease the need for multiple appointments and decrease patient anxiety by discussing breast density and screening choices prior to the patient's screening mammography. The great majority of patients will receive the correct information about their breast density by using a prior report.