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Mammography is an important tool in the early detection of breast cancer. However, the perceptual task is difficult and a significant proportion of cancers are missed. Visual search experiments show that miss (false negative) errors are elevated when targets are rare (low prevalence) but it is unknown if low prevalence is a significant factor under real world, clinical conditions. Here we show that expert mammographers in a real, low-prevalence, clinical setting, miss a much higher percentage of cancers than are missed when the mammographers search for the same cancers under high prevalence conditions. We inserted 50 positive and 50 negative cases into the normal workflow of the breast cancer screening service of an urban hospital over the course of nine months. This rate was slow enough not to markedly raise disease prevalence in the radiologists’ daily practice. Six radiologists subsequently reviewed all 100 cases in a session where the prevalence of disease was 50%. In the clinical setting, participants missed 30% of the cancers. In the high prevalence setting, participants missed just 12% of the same cancers. Under most circumstances, this low prevalence effect is probably adaptive. It is usually wise to be conservative about reporting events with very low base rates (Was that a flying saucer? Probably not.). However, while this response to low prevalence appears to be strongly engrained in human visual search mechanisms, it may not be as adaptive in socially important, low prevalence tasks like medical screening. While the results of any one study must be interpreted cautiously, these data are consistent with the conclusion that this behavioral response to low prevalence could be a substantial contributor to miss errors in breast cancer screening. [ABSTRACT FROM AUTHOR]

The Mammography Quality Standards Act (MQSA) took the voluntary peer review process of the American College of Radiology (ACR) Mammography Accreditation Program (MAP) and used it for the foundation of a stringent set of federal regulations.  By mandating accreditation, certification, and inspection for all providers, the legislative objective was to assure American women that they have the equal opportunity for quality breast cancer screening no matter where they reside.  However, as with any government regulation there is an inherent cost to the regulated community.  This article will address the need for regulation, the positive impact and the additional burdens that have resulted. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Influence of computer-aided detection on performance of screening mammography," by J.J. Fenton, S.H. Taplin and colleagues in the April 5, 2007 issue.

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

To describe the appearance of isolated intraductal papilloma on contrast-enhanced water-specific, high spatial-resolution and rapid dynamic breast MRI, a retrospective review of unilateral breast images of 15 pathologically proven papilloma was performed. MRI revealed three patterns: Four papillomas were small, smooth, enhancing masses at the posterior end of an enlarged duct, corresponding to the “small lumenal mass” appearance of papilloma known from galactography. MRI detected two of these “small lumenal mass” papillomas in patients with abnormal nipple discharge even when galactography was unsuccessful. Seven papillomas were irregular enhancing masses detected in patients without nipple discharge. None of these papillomas had specifically benign findings. All seven demonstrated rapid enhancement and three showed rim enhancement or spiculation. These “tumor-like” papillomas mimicked invasive breast cancer on MRI. Four papillomas were occult on MRI, not revealed by either contrast-enhanced MRI or fat-suppressed T2-weighted MRI. Intraductal papillomas present with a variable appearance on MRI ranging from occult to “small lumenal mass” papillomas to irregular rapidly enhancing lesions that cannot be distinguished from invasive cancers. [Copyright &y& Elsevier]

The article argues on state laws on breast-density in the U.S. It states that the implementation of these state laws vary in requiring physicians to advise women with dense breasts to undergo supplemental whole-breast ultrasonography in early cancer detection and mandate insurers to cover the additional screening. Also mentioned are the limitation of radiologic reporting system and slow adoption of computer algorithms.

Background: Little is known about older women's experience with a benign breast biopsy.Objectives: To examine the psychological impact and experience of women ≥ 65 years of age with a benign breast biopsy.Design: Prospective cohort study using quantitative and qualitative methods.Setting: Three Boston-based breast imaging centers.Participants: Ninety-four English-speaking women ≥ 65 years without dementia referred for breast biopsy as a result of an abnormal mammogram, not aware of their biopsy results at baseline, and with a subsequent negative biopsy.Measurements: We interviewed women at the time of breast biopsy (before women knew their results) and 6 months post-biopsy. At both interviews, participants completed the validated negative psychological consequences of screening mammography questionnaire (PCQ, scores range from 0 to 36 [high distress], PCQ ≥ 1 suggests a psychological consequence, PCQs <1 are reported at time of screening) and women responded to open-ended questions about their experience. At follow-up, participants described the quality of information received after their benign breast biopsy. We used a linear mixed effects model to examine if PCQs declined over time. We also reviewed participants' open-ended comments for themes.Results: Overall, 88% (83/94) of participants were non-Hispanic white and 33% (31/94) had a high-school degree or less. At biopsy, 76% (71/94) reported negative psychological consequences from their biopsy compared to 39% (37/94) at follow-up (p < 0.01). In open-ended comments, participants noted the anxiety (29%, 27/94) and discomfort (28%, 26/94) experienced at biopsy (especially from positioning on the biopsy table). Participants requested more information to prepare for a biopsy and to interpret their negative results. Forty-four percent (39/89) reported at least a little anxiety about future mammograms.Conclusions: The high psychological burden of a benign breast biopsy among older women significantly diminishes with time but does not completely resolve. To reduce this burden, older women need more information about undergoing a breast biopsy. [ABSTRACT FROM AUTHOR]

Very fast extraction of global structural and statistical regularities allows us to access the “gist”—the basic meaning—of real-world images in as little as 20 ms. Gist processing is central to efficient assessment and orienting in complex environments. This ability is probably based on our extensive experience with the regularities of the natural world. If that is so, would experts develop an ability to extract the gist from the artificial stimuli (e.g., medical images) with which they have extensive visual experience? Anecdotally, experts report some ability to categorize images as normal or abnormal before actually finding an abnormality. We tested the reality of this perception in two expert populations: radiologists and cytologists. Observers viewed brief (250- to 2,000-ms) presentations of medical images. The presence of abnormality was randomized across trials. The task was to rate the abnormality of an image on a 0–100 analog scale and then to attempt to localize that abnormality on a subsequent screen showing only the outline of the image. Both groups of experts had above-chance performance for detecting subtle abnormalities at all stimulus durations (cytologists d' ≈ 1.2 and radiologists d' ≈ 1), whereas the nonexpert control groups did not differ from chance ( d' ≈ 0.23, d' ≈ 0.25). Furthermore, the experts’ ability to localize these abnormalities was at chance levels, suggesting that categorization was based on a global signal, and not on fortuitous attention to a localized target. It is possible that this global signal could be exploited to improve clinical performance. [ABSTRACT FROM AUTHOR]

To assess which specific morphologic features, enhancement patterns, or pharmacokinetic parameters on breast Magnetic Resonance Imaging (MRI) could predict a false-negative outcome of Proton MR Spectroscopy (1H MRS) exam in patients with invasive breast cancer. Sixteen patients with invasive ductal carcinoma of the breast were prospectively included and underwent both, contrast-enhanced breast MRI and 1H MRS examination of the breast. The MR images were reviewed and the lesions morphologic features, enhancement patterns and pharmacokinetic parameters (k21-value) were scored according to the ACR BI-RADS-MRI lexicon criteria. For the in vivo MRS studies, each spectrum was evaluated for the presence of choline based on consensus reading. Breast MRI and 1H MRS data were compared to histopathologic findings. In vivo 1H MRS detected a choline peak in 14/16 (88%) cancers. A false-negative 1H MRS study occurred in 2/16 (14%) cancer patients. K21 values differed between both groups: the 14 choline positive cancers had k21 values ranging from 0.01 to 0.20/second (mean 0.083/second), whereas the two choline-negative cancers showed k21 values of 0.03 and 0.05/second, respectively (mean 0.040/second). Also enhancement kinetics did differ between both groups; typically both cancers that were choline-negative showed a late phase plateau (100%), whereas this was only shown in 5/14 (36%) of the choline positive cases. There was no difference between both groups with regard to morphologic features on MRI. This study showed that false-negative 1H MRS examinations do occur in breast cancer patients, and that the presence of a choline peak on 1H MRS as malignancy marker is related to the k21 value of the invasive tumor being imaged. [ABSTRACT FROM AUTHOR]

Treatment regimens for Hodgkin’s disease (HD) that have included radiation to lymph node regions in the thorax have contributed to high rates of long-term disease-free survival. However, incidental radiation exposure of breast tissue in young women has significantly increased the risk of breast cancer compared to expected rates in the general population. After informing patients about risks associated with previous treatment of HD, we studied screening mammograms and call-back rates in women at increased risk for developing breast cancer at a younger age. We contacted by mail a cohort of 291 women between 25 and 55 years of age who had received thoracic irradiation before 35 years of age for HD with or without chemotherapy. Subjects were offered information about risks identified after HD therapy with questionnaires to assess response to this information. Ten patients refused participation, 93 did not respond, and 21 were excluded after they reported a prior diagnosis of invasive ( 1 ) or in situ ( 2 ) breast cancer. One hundred and sixty seven women received information about secondary breast cancer risk and were advised to initiate or maintain mammographic screening. Available mammograms were reviewed by two radiologists and classified according to the ACR BI-RADSTM Mammography Lexicon. Abnormal findings were correlated to pathology results from biopsies. One hundred and fifteen subjects reported that they obtained new mammograms during the period of the study. Ninety-nine were available for secondary review. Patients were studied an average of 16.9 years after HD treatment (Range: 4.5–32.5 years) at an average of 41 years of age (range 25–55 years). High density breast tissue was identified in 60% (60/99). Seventeen of the women (17.2%) were recalled for further imaging. This was more common in women with heterogeneously dense breast tissue. Seven of those recalled (41%) were advised to undergo biopsies that identified ductal carcinoma in situ (DCIS) in one and benign findings in the others. Among 16 women whose mammograms were unavailable for review, three were diagnosed with DCIS; two of these had microscopic evidence of invasive breast cancer. The four in situ or microinvasive cancers were diagnosed in the study participants at 25–40 years of age and from 5 to 23 years after HD therapy. Biopsies were performed because mammograms detected microcalcifications without palpable abnormality in three of these cases. Women who have had thoracic nodal irradiation for Hodgkin’s disease have an increased risk of developing secondary breast cancer at an unusually young age. As expected in younger women, high density breast tissue was common on mammography, and the recall and biopsy rates were unusually high. However, early mammographic screening facilitated diagnosis of in situ and early invasive cancer in 3.5% of our subjects. [ABSTRACT FROM AUTHOR]

Background: We performed this study to determine rates of close or transected cancer margins after magnetic resonance imaging-guided bracket wire localization for nonpalpable breast lesions. Study design: Of 243 women undergoing MRI-guided wire localizations, 26 had MRI bracket wire localization to excise either a known cancer (n = 19) or a suspicious MRI-detected lesion (n = 7). We reviewed patient age, preoperative diagnosis, operative intent, mammographic breast density, MRI lesion size, MRI enhancement curve and morphology, MRI Breast Imaging Reporting and Data System (BI-RADS) assessment code, number of bracket wires, and pathology size. We analyzed these findings for their relationship to obtaining clear margins at first operative excision. Results: Twenty-one of 26 (81%) patients had cancer. Of 21 patients with cancer, 12 (57%) had negative margins at first excision and 9 (43%) had close/transected margins. MRI size ≥ 4 cm was associated with a higher reexcision rate (7 of 9, 78%) than those &#60; 4 cm (2 of 12, 17%) (p = 0.009). MRI BI-RADS score, enhancement curve, morphology, and preoperative core biopsy demonstrating ductal carcinoma in situ (DCIS) were not predictive of reexcision. The average number of wires used for bracketing increased with lesion size, but was not associated with improved outcomes. On pathology, cancer size was smaller in patients with negative margins (12 patients, 1.2 cm) than in those with close/transected margins (9 patients, 4.6 cm) (p &#60; 0.001). Reexcision was based on close/transected margins involving DCIS alone (6, 67%), infiltrating ductal carcinoma and DCIS (2, 22%), or infiltrating ductal carcinoma alone (1, 11%). Reexcision pathology demonstrated DCIS (3, 33%), no residual cancer (5, 55%), and 1 patient was lost to followup (1, 11%). Interestingly, cancer patients who required reexcision were younger (p = 0.022), but breast density was not associated with reexcision. Conclusions: To our knowledge, this is the first report of MRI-guided bracket wire localization. Patients with MRI-detected lesions less than 4 cm had clear margins at first excision; larger MRI-detected lesions were more likely to have close/transected margins. Reexcision was often because of DCIS and was the only pathology found at reexcision, perhaps because MRI is more sensitive for detecting invasive carcinoma than DCIS. [Copyright &y& Elsevier]