Breast Cancer Disparity and Outcomes in Underserved Women.

Women in the United States who continue to face obstacles accessing health care are frequently termed an underserved population. Safety-net health care systems play a crucial role in mitigating health disparities and reducing burdens of disease, such as breast cancer, for underserved women. Disparities in health care are driven by various factors, including race and ethnicity, as well as socioeconomic factors that affect education, employment, housing, insurance status, and access to health care. Underserved women are more likely to be uninsured or underinsured throughout their lifetimes. Hence they have greater difficulty gaining access to breast cancer screening and are less likely to undergo supplemental imaging when needed. Therefore, underserved women often experience significant delays in the diagnosis and treatment of breast cancer, leading to higher mortality rates. Addressing disparities requires a multifaceted approach, with formal care coordination to help at-risk women navigate through screening, diagnosis, and treatment. Mobile mammography units and community outreach programs can be leveraged to increase community access and engagement, as well as improve health literacy with educational initiatives. Radiology-community partnerships, comprised of imaging practices partnered with local businesses, faith-based organizations, homeless shelters, and public service departments, are essential to establish culturally competent breast imaging care, with the goal of equitable access to early diagnosis and contemporary treatment. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the Online Learning Center. See the invited commentary by Leung in this issue.

Diagnostic Evaluation of Recalled Noncalcified Lesions Using Ultrasound Alone Versus Ultrasound Plus Additional Mammographic Views: A Prospective Study.

BACKGROUND. The diagnostic performance of digital breast tomosynthesis (DBT) has been shown to be equal to that of diagnostic mammography. However, the value of additional mammographic views in diagnostic evaluations remains unclear. OBJECTIVE. The purpose of this study was to compare the performance of diagnostic breast ultrasound (US) alone with that of combined US and diagnostic mammography for specific noncalcified recalled abnormalities detected on screening DBT. METHODS. This was a prospective study with a single-arm management strategy. Women recalled for noncalcified lesions on screening DBT underwent initial diagnostic US as part of the study protocol. Additional diagnostic mammography was performed at the discretion of the radiologist. Imaging assessment decisions determined by BI-RADS assessments and management recommendations, biopsy outcomes, and follow-up were recorded using case report forms completed on the day of the diagnostic evaluation and stored in the electronic medical record. RESULTS. From July 10, 2017, to June 6, 2019, a total of 430 recalled noncalcified lesions in 399 women (mean age, 60 ± 12 [SD] years) were included. US alone was performed for 71.2% (306/430) of lesions, whereas US with diagnostic mammography was performed for 28.8% (124/430). Of the recalled lesions, 93.7% (178/190) of masses, 60.0% (51/85) of focal asymmetries, 46.1% (53/115) of asymmetries, 69.2% (9/13) of developing asymmetries, and 55.6% (15/27) of architectural distortions were evaluated with US alone. Of 93 lesions that underwent needle biopsy, 40.9% (38/93) were cancers, all of which were invasive. Thirty-five of 38 (92.1%) cancers were evaluated by US alone, whereas three (7.9%) were evaluated with US and diagnostic mammography. At a median follow-up of 25 months, six cancers were identified (three with US alone and three with US plus diagnostic mammography) in patients with initially benign workup. US alone had two false-negative cancers (one architectural distortion identified at follow-up and one mass biopsied stereotactically at initial detection). CONCLUSION. US alone is effective in the diagnostic evaluation of noncalcified masses recalled on screening tomosynthesis. For asymmetries, diagnostic mammography may be best without the need for additional US, whereas architectural distortions still warrant diagnostic mammography and US. CLINICAL IMPACT. Radiologists should consider performing US first for DBT-recalled noncalcified masses. Omitting diagnostic mammography when US is negative has a low false-negative rate.

Axillary Lymphadenopathy in the COVID-19 Era: What the Radiologist Needs to Know.

Axillary lymphadenopathy caused by the high immunogenicity of messenger RNA (mRNA) COVID-19 vaccines presents radiologists with new diagnostic dilemmas in differentiating vaccine-related benign reactive lymphadenopathy from that due to malignant causes. Understanding axillary anatomy and lymphatic drainage is key to radiologic evaluation of the axilla. US plays a critical role in evaluation and classification of axillary lymph nodes on the basis of their cortical and hilar morphology, which allows prediction of metastatic disease. Guidelines for evaluation and management of axillary lymphadenopathy continue to evolve as radiologists gain more experience with axillary lymphadenopathy related to COVID-19 vaccines. General guidelines recommend documenting vaccination dates and laterality and administering all vaccine doses contralateral to the site of primary malignancy whenever applicable. Guidelines also recommend against postponing imaging for urgent clinical indications or for treatment planning in patients with newly diagnosed breast cancer. Although conservative management approaches to axillary lymphadenopathy initially recommended universal short-interval imaging follow-up, updates to those approaches as well as risk-stratified approaches recommend interpreting lymphadenopathy in the context of both vaccination timing and the patient's overall risk of metastatic disease. Patients with active breast cancer in the pretreatment or peritreatment phase should be evaluated with standard imaging protocols regardless of vaccination status. Tissue sampling and multidisciplinary discussion remain useful in management of complex cases, including increasing lymphadenopathy at follow-up imaging, MRI evaluation of extent of disease, response to neoadjuvant treatment, and potentially confounding cases. An invited commentary by Weinstein is available online. ©RSNA, 2022.

New horizons in imaging and surgical assessment of breast cancer lymph node metastasis.

Axillary nodal status is one of the most important prognostic factors in breast cancer. While sentinel lymph node biopsy (SLNB) is a safe and validated procedure for clinically node-negative patients, axillary management of clinically node-positive patients has been more controversial. Patients with clinically detected axillary metastases often benefit from neoadjuvant chemotherapy (NAC). Those who convert to node-negative disease following NAC are important to identify, since they can often be spared significant morbidity from axillary dissection. SLNB has shown widely varying false-negative rates (FNR) but with the use of dual mapping and surgical biopsy of 3 or more nodes, it is considered an acceptable method to stage the axilla in clinically node-positive patients who receive NAC. Various methods including targeted axillary dissection (TAD) have been shown to decrease the FNR of SLNB. We will review appropriate methods to identify a metastatic node and subsequent ultrasound-guided biopsy with tissue marking techniques. We underscore key points in monitoring axillary response, techniques to accurately localize the biopsied and clipped known metastatic node for surgical excision and the effect of various methods in reducing the FNR of SLNB, including the emerging concept of TAD on patient care.

Multimodality Imaging-based Evaluation of Single-Lumen Silicone Breast Implants for Rupture.

Breast implants are frequently encountered on breast imaging studies, and it is essential for any radiologist interpreting these studies to be able to correctly assess implant integrity. Ruptures of silicone gel-filled implants often occur without becoming clinically obvious and are incidentally detected at imaging. Early diagnosis of implant rupture is important because surgical removal of extracapsular silicone in the breast parenchyma and lymphatics is difficult. Conversely, misdiagnosis of rupture may prompt a patient to undergo unnecessary additional surgery to remove the implant. Mammography is the most common breast imaging examination performed and can readily depict extracapsular free silicone, although it is insensitive for detection of intracapsular implant rupture. Ultrasonography (US) can be used to assess the internal structure of the implant and may provide an economical method for initial implant assessment. Common US signs of intracapsular rupture include the "keyhole" or "noose" sign, subcapsular line sign, and "stepladder" sign; extracapsular silicone has a distinctive "snowstorm" or echogenic noise appearance. Magnetic resonance (MR) imaging is the most accurate and reliable means for assessment of implant rupture and is highly sensitive for detection of both intracapsular and extracapsular rupture. MR imaging findings of intracapsular rupture include the keyhole or noose sign, subcapsular line sign, and "linguine" sign, and silicone-selective MR imaging sequences are highly sensitive to small amounts of extracapsular silicone. ©RSNA, 2017.

A Tale of Two Hospitals: Effect of Access to Care Through a Safety Net Hospital on Adjuvant Therapy, Imaging Compliance and 5-Year Survival Rates Compared to the University Hospital Served by the Same Breast Cancer Clinical Teams.

RATIONALE AND OBJECTIVES: To compare rates of guideline-concordant care, imaging surveillance, recurrence and survival outcomes between a safety-net (SNH) and tertiary-care University Hospital (UH) served by the same breast cancer clinical teams. MATERIALS AND METHODS: 647 women with newly diagnosed breast cancer treated in affiliated SNH and UH between 11.1.2014 and 3.31.2017 were reviewed. Patient demographics, completion of guideline-concordant adjuvant chemotherapy, radiation and hormonal therapy were recorded. Two multivariable logistic regression models were performed to investigate the effect of hospital and race on cancer stage. Kaplan-Meier log-rank and Cox-regression were used to analyze five-year recurrence-free (RFS) and overall survival (OS) between hospitals and races, (p < 0.05 significant). RESULTS: Patients in SNH were younger (mean SNH 53.2 vs UH 57.9, p < 0.001) and had higher rates of cT3/T4 disease (SNH 19% vs UH 5.5%, p < 0.001). Patients in the UH had higher rates of bilateral mastectomy (SNH 17.6% vs UH 40.1% p < 0.001) while there was no difference in the positive surgical margin rate (SNH 5.0% vs UH 7.6%, p = 0.20), completion of adjuvant radiation (SNH 96.9% vs UH 98.7%, p = 0.2) and endocrine therapy (SNH 60.8% vs UH 66.2%, p = 0.20). SNH patients were less compliant with mammography surveillance (SNH 64.1% vs UH 75.1%, p = 0.02) and adjuvant chemotherapy (SNH 79.1% vs UH 96.3%, p < 0.01). RFS was lower in the SNH (SNH 54 months vs UH 57 months, HR 1.90, 95% CI: 1.18-3.94, p = 0.01) while OS was not significantly different (SNH 90.5% vs UH 94.2%, HR 1.78, 95% CI: 0.97-3.26, p = 0.06). CONCLUSION: In patients experiencing health care disparities, having access to guideline-concordant care through SNH resulted in non-inferior OS to those in tertiary-care UH.

Imaging of COVID-19 Vaccine-Related Axillary Lymphadenopathy: Initial Outcomes Based on US Features of Axillary Lymph Nodes.

OBJECTIVE: The purpose of this study is to describe the imaging characteristics and outcomes of COVID-19 vaccine-related axillary adenopathy and subsequent follow-up. METHODS: This was an IRB-approved, retrospective study of patients with imaging evidence of axillary lymphadenopathy who had received at least one dose of a COVID-19 vaccine and presented between January 1, 2021, and February 28, 2021. Sonographic cortical thickness and morphology was evaluated. A mixed effects model was used to model lymph node cortical thickness decrease over time. RESULTS: A total of 57 women were identified with lymphadenopathy and a COVID vaccination during the study period with 51 (89.5%) women completing imaging surveillance or undergoing tissue sampling of a lymph node. Three women (5.9%) were diagnosed with metastatic breast cancer to an axillary node. There was a statistically significant correlation with cortical thickness at initial US evaluation and malignancy (7.7 mm [SD ±â€…0.6 mm] for metastatic nodes and 5 mm [SD ±â€…2 mm] for benign nodes, P = 0.02). Suspicious morphological features (effacement of fatty hilum, P = 0.02) also correlated with malignancy. Time to resolution of lymphadenopathy can be prolonged with estimated half-life of the rate of decrease in cortical thickness modeled at 77 days (95% CI, 59-112 days). Diffuse, smooth cortical thickening over 3 mm was the most common lymph node morphology. CONCLUSION: Malignant lymph node morphology and cortical thickness best predicted malignancy. Benign hyperplastic lymph nodes were the most common morphology observed after COVID-19 vaccination. Lymphadenopathy after vaccination is slow to resolve.

Large Desmoid Tumor in the Setting of Prior Cosmetic Breast Augmentation.

Desmoid tumors of the breast are rare, comprising 0.2% of all breast tumors. They may be locally invasive but do not metastasize. The etiology is multifactorial including surgical trauma in the setting of prior cosmetic augmentation breast implants. We submit a case of a large desmoid tumor in the breast following silicone implant placement three years prior to patient presentation. The patient was treated with wide local excision to negative margins and implant exchange. A follow up breast magnetic resonance imaging at 3 and 6 months did not detect a recurrence thus far.

Health Care Disparities in Breast Cancer: The Economics of Access to Screening, Diagnosis, and Treatment.

The widespread acceptance of screening mammography for early detection, along with advances in treatment, have combined to decrease the overall mortality rate from breast cancer. However, significant disparities in health outcomes persist. Socioeconomic factors, including the ability to obtain private insurance, income, education, disparities in the quality of healthcare delivery, and race, as well as the ability to access and complete the most advanced breast cancer treatments, form part of a complex constellation of factors that contribute to disparity in breast cancer mortality. Here, we review some of the factors influencing this disparity and discuss some of the methods that have been suggested for closing the gap in breast cancer outcomes, using our perspective as breast imaging physicians serving both a safety-net hospital and tertiary healthcare system.

Choice of imaging method in the work-up of non-calcified breast lesions identified on tomosynthesis screening.

PURPOSE: The purpose of this study is to compare the use of diagnostic mammography, diagnostic mammography with ultrasound, and ultrasound alone in the evaluation of recalled non-calcified lesions from screening mammography with digital breast tomosynthesis (DBT). METHODS: We performed a retrospective review of recalled non-calcified lesions that included architectural distortion, asymmetry, focal asymmetry and mass from screening DBT from January 2014 to December 2016. Electronic health records were reviewed for imaging evaluations, findings and histopathology results. RESULTS: Of 266 non-calcified lesions in 247 women, masses were significantly more likely to be evaluated with ultrasound alone compared to diagnostic mammography with ultrasound than all other recalled finding types (OR = 7.63; 95 %CI [4.17-13.97]; p < 0.01). Architectural distortions were more likely to be assigned a BI-RADS 4 or 5 on the diagnostic evaluation than all other lesion types (OR = 7.71; 95 %CI [2.82-21.04]; p < 0.01). Masses were more likely to be true lesions (90 %; 111/124) compared to 40 % (23/57) of focal asymmetries (OR = 11.41; 95 %CI [4.05-32.14]; p < 0.01) and 24 % (16/67) of asymmetries (OR = 27.01; 95 %CI [9.41-77.48]; p < 0.01). No significant difference was noted in the malignant versus benign biopsy outcomes among the recalled DBT lesion types (p = 0.71). CONCLUSION: Recalled masses from screening DBT were more likely to be worked up with ultrasound alone compared to all other non-calcified lesion types and more likely to represent true lesions on diagnostic evaluation. Recalled asymmetries and focal asymmetries were more likely to be worked up with either diagnostic mammography with ultrasound or diagnostic mammography alone.

Is There a Difference in the Diagnostic Outcomes of Calcifications Initially Identified on Synthetic Tomosynthesis Versus Full-Field Digital Mammography Screening?

PURPOSE: To compare the outcomes of microcalcifications recalled on full-field digital (FFDM) and FFDM and combined tomosynthesis (Combo) to synthetic (SM) screening mammograms. METHOD: We reviewed medical records, radiology, and pathology reports of all patients found to have abnormal calcifications requiring further evaluation on mammography screening at our institution between 11/1/2016-11/1/2018 and collected patient demographics, calcification morphology and distribution, and mammography technique (SM, FFDM, or Combo). We used biopsy pathology or at least 1-year imaging follow-up to establish overall diagnostic outcome (benign or malignant). Fisher's exact test was used to compare validation rates at diagnostic work-up, BI-RADS category, and final outcome of calcifications identified on each screening technique. T-test was used for continuous variables. RESULTS: Of 699 calcifications in 596 women recalled, 176 (30%) of 596 were from SM and 420 (70%) FFDM/Combo. There was a significantly higher rate of calcifications unvalidated at diagnostic work-up for SM compared to FFDM/Combo (0.8% vs. 10%, p < 0.0001). SM calcifications were more likely to receive BI-RADS 2/3 at diagnostic work-up compared to FFDM/Combo ones (55% vs. 42%, p = 0.003). Of 346 (49%) calcifications that underwent biopsy, 88 (25%) were malignant (36% of SM vs. 22% of FFDM/Combo, OR:0.5 [95% CI: 0.3, 0.8] p = 0.01). Of 622 lesions with established diagnostic outcome, there was no difference between having an overall benign or malignant outcome between SM and FFDM/Combo (17% vs. 13%, OR: 0.8 [95% Cl: 0.5, 1.2] p = 0.27). CONCLUSIONS: Synthetic tomosynthesis screening results in a higher rate of false positive and unvalidated calcification recalls compared to FFDM/Combo.

Changing Paradigms in Breast Cancer Screening: Abbreviated Breast MRI.

Breast magnetic resonance imaging (MRI) is the most sensitive imaging method for breast cancer detection. In this review we discuss the vastly superior performance of MRI compared to traditional breast cancer screening modalities of mammography, tomosynthesis and ultrasound. We discuss an abbreviated breast MRI (AB-MRI) protocol utilizing Dixon sequences which is compliant with American College of Radiology (ACR) guidelines for accreditation of breast MRI but with significantly reduced scan times. Adaptation of such an AB-MRI protocol significantly increases patient throughput and may allow MRI to serve as a stand- alone breast cancer screening tool.