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Background: Annual surveillance mammography is recommended for women with a personal history of breast cancer. Risk prediction models that estimate mammography failures such as interval second breast cancers could help to tailor surveillance imaging regimens to women's individual risk profiles., Methods: In a cohort of women with a history of breast cancer receiving surveillance mammography in the Breast Cancer Surveillance Consortium in 1996-2019, we used Least Absolute Shrinkage and Selection Operator (LASSO)-penalized regression to estimate the probability of an interval second cancer (invasive cancer or ductal carcinoma in situ) in the 1 year after a negative surveillance mammogram. Based on predicted risks from this one-year risk model, we generated cumulative risks of an interval second cancer for the five-year period after each mammogram. Model performance was evaluated using cross-validation in the overall cohort and within race and ethnicity strata., Results: In 173 290 surveillance mammograms, we observed 496 interval cancers. One-year risk models were well-calibrated (expected/observed ratio = 1.00) with good accuracy (area under the receiver operating characteristic curve = 0.64). Model performance was similar across race and ethnicity groups. The median five-year cumulative risk was 1.20% (interquartile range 0.93%-1.63%). Median five-year risks were highest in women who were under age 40 or pre- or perimenopausal at diagnosis and those with estrogen receptor-negative primary breast cancers., Conclusions: Our risk model identified women at high risk of interval second breast cancers who may benefit from additional surveillance imaging modalities. Risk models should be evaluated to determine if risk-guided supplemental surveillance imaging improves early detection and decreases surveillance failures., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: To summarize the literature regarding the performance of mammography-image based artificial intelligence (AI) algorithms, with and without additional clinical data, for future breast cancer risk prediction., Materials and Methods: A systematic literature review was performed using six databases (medRixiv, bioRxiv, Embase, Engineer Village, IEEE Xplore, and PubMed) from 2012 through September 30, 2022. Studies were included if they used real-world screening mammography examinations to validate AI algorithms for future risk prediction based on images alone or in combination with clinical risk factors. The quality of studies was assessed, and predictive accuracy was recorded as the area under the receiver operating characteristic curve (AUC)., Results: Sixteen studies met inclusion and exclusion criteria, of which 14 studies provided AUC values. The median AUC performance of AI image-only models was 0.72 (range 0.62-0.90) compared with 0.61 for breast density or clinical risk factor-based tools (range 0.54-0.69). Of the seven studies that compared AI image-only performance directly to combined image + clinical risk factor performance, six demonstrated no significant improvement, and one study demonstrated increased improvement., Conclusions: Early efforts for predicting future breast cancer risk based on mammography images alone demonstrate comparable or better accuracy to traditional risk tools with little or no improvement when adding clinical risk factor data. Transitioning from clinical risk factor-based to AI image-based risk models may lead to more accurate, personalized risk-based screening approaches., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background It is important to establish screening mammography performance benchmarks for quality improvement efforts. Purpose To establish performance benchmarks for digital breast tomosynthesis (DBT) screening and evaluate performance trends over time in U.S. community practice. Materials and Methods In this retrospective study, DBT screening examinations were collected from five Breast Cancer Surveillance Consortium (BCSC) registries between 2011 and 2018. Performance measures included abnormal interpretation rate (AIR), cancer detection rate (CDR), sensitivity, specificity, and false-negative rate (FNR) and were calculated based on the American College of Radiology Breast Imaging Reporting and Data System, fifth edition, and compared with concurrent BCSC DM screening examinations, previously published BCSC and National Mammography Database benchmarks, and expert opinion acceptable performance ranges. Benchmarks were derived from the distribution of performance measures across radiologists ( n = 84 or n = 73 depending on metric) and were presented as percentiles. Results A total of 896 101 women undergoing 2 301 766 screening examinations (458 175 DBT examinations [median age, 58 years; age range, 18-111 years] and 1 843 591 DM examinations [median age, 58 years; age range, 18-109 years]) were included in this study. DBT screening performance measures were as follows: AIR, 8.3% (95% CI: 7.5, 9.3); CDR per 1000 screens, 5.8 (95% CI: 5.4, 6.1); sensitivity, 87.4% (95% CI: 85.2, 89.4); specificity, 92.2% (95% CI: 91.3, 93.0); and FNR per 1000 screens, 0.8 (95% CI: 0.7, 1.0). When compared with BCSC DM screening examinations from the same time period and previously published BCSC and National Mammography Database performance benchmarks, all performance measures were higher for DBT except sensitivity and FNR, which were similar to concurrent and prior DM performance measures. The following proportions of radiologists achieved acceptable performance ranges with DBT: 97.6% for CDR, 91.8% for sensitivity, 75.0% for AIR, and 74.0% for specificity. Conclusion In U.S. community practice, large proportions of radiologists met acceptable performance ranges for screening performance metrics with DBT. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Lee and Moy in this issue.

Background: Estimating advanced breast cancer risk in women undergoing annual or biennial mammography could identify women who may benefit from less or more intensive screening. We developed an actionable model to predict cumulative 6-year advanced cancer (prognostic pathologic stage II or higher) risk according to screening interval., Methods: We included 931 186 women aged 40-74 years in the Breast Cancer Surveillance Consortium undergoing 2 542 382 annual (prior mammogram within 11-18 months) or 752 049 biennial (prior within 19-30 months) screening mammograms. The prediction model includes age, race and ethnicity, body mass index, breast density, family history of breast cancer, and prior breast biopsy subdivided by menopausal status and screening interval. We used fivefold cross-validation to internally validate model performance. We defined higher than 95th percentile as high risk (>0.658%), higher than 75th percentile to 95th or less percentile as intermediate risk (0.380%-0.658%), and 75th or less percentile as low to average risk (<0.380%)., Results: Obesity, high breast density, and proliferative disease with atypia were strongly associated with advanced cancer. The model is well calibrated and has an area under the receiver operating characteristics curve of 0.682 (95% confidence interval = 0.670 to 0.694). Based on women's predicted advanced cancer risk under annual and biennial screening, 69.1% had low or average risk regardless of screening interval, 12.4% intermediate risk with biennial screening and average risk with annual screening, and 17.4% intermediate or high risk regardless of screening interval., Conclusion: Most women have low or average advanced cancer risk and can undergo biennial screening. Intermediate-risk women may consider annual screening, and high-risk women may consider supplemental imaging in addition to annual screening., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The coronavirus disease 2019 (COVID-19) pandemic led to a near-total cessation of mammography services in the United States in mid-March 2020. It is unclear if screening and diagnostic mammography volumes have recovered to prepandemic levels and whether use has varied by women's characteristics., Methods: We collected data on 461 083 screening mammograms and 112 207 diagnostic mammograms conducted during January 2019 through July 2020 at 62 radiology facilities in the Breast Cancer Surveillance Consortium. We compared monthly screening and diagnostic mammography volumes before and during the pandemic stratified by age, race and ethnicity, breast density, and family history of breast cancer., Results: Screening and diagnostic mammography volumes in April 2020 were 1.1% (95% confidence interval [CI] = 0.5% to 2.4%) and 21.4% (95% CI = 18.7% to 24.4%) of the April 2019 prepandemic volumes, respectively, but by July 2020 had rebounded to 89.7% (95% CI = 79.6% to 101.1%) and 101.6% (95% CI = 93.8% to 110.1%) of the July 2019 prepandemic volumes, respectively. The year-to-date cumulative volume of screening and diagnostic mammograms performed through July 2020 was 66.2% (95% CI = 60.3% to 72.6%) and 79.9% (95% CI = 75.4% to 84.6%), respectively, of year-to-date volume through July 2019. Screening mammography rebound was similar across age groups and by family history of breast cancer. Monthly screening mammography volume in July 2020 for Black, White, Hispanic, and Asian women reached 96.7% (95% CI = 88.1% to 106.1%), 92.9% (95% CI = 82.9% to 104.0%), 72.7% (95% CI = 56.5% to 93.6%), and 51.3% (95% CI = 39.7% to 66.2%) of the July 2019 prepandemic volume, respectively., Conclusions: Despite a strong overall rebound in mammography volume by July 2020, the rebound lagged among Asian and Hispanic women, and a substantial cumulative deficit in missed mammograms accumulated, which may have important health consequences., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background Since 2007, digital mammography and digital breast tomosynthesis (DBT) replaced screen-film mammography. Whether these technologic advances have improved diagnostic performance has, to the knowledge of the authors, not yet been established. Purpose To evaluate the performance and outcomes of surveillance mammography (digital mammography and DBT) performed from 2007 to 2016 in women with a personal history of breast cancer and compare with data from 1996 to 2007 and the performance of digital mammography screening benchmarks. Materials and Methods In this observational cohort study, five Breast Cancer Surveillance Consortium registries provided prospectively collected mammography data linked with tumor registry and pathologic outcomes. This study identified asymptomatic women with American Joint Committee on Cancer anatomic stages 0-III primary breast cancer who underwent surveillance mammography from 2007 to 2016. The primary outcome was a second breast cancer diagnosis within 1 year of mammography. Performance measures included the recall rate, cancer detection rate, interval cancer rate, positive predictive value of biopsy recommendation, sensitivity, and specificity. Results Among 32 331 women who underwent 117 971 surveillance mammographic examinations (112 269 digital mammographic examinations and 5702 DBT examinations), the mean age at initial diagnosis was 59 years ± 12 (standard deviation). Of 1418 second breast cancers diagnosed, 998 were surveillance-detected cancers and 420 were interval cancers. The recall rate was 8.8% (10 365 of 117 971; 95% CI: 8.6%, 9.0%), the cancer detection rate was 8.5 per 1000 examinations (998 of 117 971; 95% CI: 8.0, 9.0), the interval cancer rate was 3.6 per 1000 examinations (420 of 117 971; 95% CI: 3.2, 3.9), the positive predictive value of biopsy recommendation was 31.0% (998 of 3220; 95% CI: 29.4%, 32.7%), the sensitivity was 70.4% (998 of 1418; 95% CI: 67.9%, 72.7%), and the specificity was 98.1% (114 331 of 116 553; 95% CI: 98.0%, 98.2%). Compared with previously published studies, interval cancer rate was comparable with rates from 1996 to 2007 in women with a personal history of breast cancer and was higher than the published digital mammography screening benchmarks. Conclusion In transitioning from screen-film to digital mammography and digital breast tomosynthesis, surveillance mammography performance demonstrated minimal improvement over time and remained inferior to the performance of screening mammography benchmarks. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Moy and Gao in this issue.

Importance: Breast cancer screening, surveillance, and diagnostic imaging services were profoundly limited during the initial phase of the coronavirus disease 2019 (COVID-19) pandemic., Objective: To develop a risk-based strategy for triaging mammograms during periods of decreased capacity., Design, Setting, and Participants: This population-based cohort study used data collected prospectively from mammography examinations performed in 2014 to 2019 at 92 radiology facilities in the Breast Cancer Surveillance Consortium. Participants included individuals undergoing mammography. Data were analyzed from August 10 to November 3, 2020., Exposures: Clinical indication for screening, breast symptoms, personal history of breast cancer, age, time since last mammogram/screening interval, family history of breast cancer, breast density, and history of high-risk breast lesion., Main Outcomes and Measures: Combinations of clinical indication, clinical history, and breast cancer risk factors that subdivided mammograms into risk groups according to their cancer detection rate were identified using classification and regression trees., Results: The cohort included 898 415 individuals contributing 1 878 924 mammograms (mean [SD] age at mammogram, 58.6 [11.2] years) interpreted by 448 radiologists, with 1 722 820 mammograms in individuals without a personal history of breast cancer and 156 104 mammograms in individuals with a history of breast cancer. Most individuals were aged 50 to 69 years at imaging (1 113 174 mammograms [59.2%]), and 204 305 (11.2%) were Black, 206 087 (11.3%) were Asian or Pacific Islander, 126 677 (7.0%) were Hispanic or Latina, and 40 021 (2.2%) were another race/ethnicity or mixed race/ethnicity. Cancer detection rates varied widely based on clinical indication, breast symptoms, personal history of breast cancer, and age. The 12% of mammograms with very high (89.6 [95% CI, 82.3-97.5] to 122.3 [95% CI, 108.1-138.0] cancers detected per 1000 mammograms) or high (36.1 [95% CI, 33.1-39.3] to 47.5 [95% CI, 42.4-53.3] cancers detected per 1000 mammograms) cancer detection rates accounted for 55% of all detected cancers and included mammograms to evaluate an abnormal mammogram or breast lump in individuals of all ages regardless of breast cancer history, to evaluate breast symptoms other than lump in individuals with a breast cancer history or without a history but aged 60 years or older, and for short-interval follow-up in individuals aged 60 years or older without a breast cancer history. The 44.2% of mammograms with very low cancer detection rates accounted for 13.1% of detected cancers and included annual screening mammograms in individuals aged 50 to 69 years (3.8 [95% CI, 3.5-4.1] cancers detected per 1000 mammograms) and all screening mammograms in individuals younger than 50 years regardless of screening interval (2.8 [95% CI, 2.6-3.1] cancers detected per 1000 mammograms)., Conclusions and Relevance: In this population-based cohort study, clinical indication and individual risk factors were associated with cancer detection and may be useful for prioritizing mammography in times and settings of decreased capacity.

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Importance: Digital mammography (DM) and digital breast tomosynthesis (DBT) are used for routine breast cancer screening. There is minimal evidence on performance outcomes by age, screening round, and breast density in community practice., Objective: To compare DM vs DBT performance by age, baseline vs subsequent screening round, and breast density category., Design, Setting, and Participants: This comparative effectiveness study assessed 1 584 079 screening examinations of women aged 40 to 79 years without prior history of breast cancer, mastectomy, or breast augmentation undergoing screening mammography at 46 participating Breast Cancer Surveillance Consortium facilities from January 2010 to April 2018., Exposures: Age, Breast Imaging Reporting and Data System breast density category, screening round, and modality., Main Outcomes and Measures: Absolute rates and relative risks (RRs) of screening recall and cancer detection., Results: Of 1 273 492 DM and 310 587 DBT examinations analyzed, 1 028 891 examinations (65.0%) were of white non-Hispanic women; 399 952 women (25.2%) were younger than 50 years; and 671 136 women (42.4%) had heterogeneously dense or extremely dense breasts. Adjusted differences in DM vs DBT performance were largest on baseline examinations: for example, per 1000 baseline examinations in women ages 50 to 59, recall rates decreased from 241 examinations for DM to 204 examinations for DBT (RR, 0.84; 95% CI, 0.73-0.98), and cancer detection rates increased from 5.9 with DM to 8.8 with DBT (RR, 1.50; 95% CI, 1.10-2.08). On subsequent examinations, women aged 40 to 79 years with heterogeneously dense breasts had improved recall rates and improved cancer detection with DBT. For example, per 1000 examinations in women aged 50 to 59 years, the number of recall examinations decreased from 102 with DM to 93 with DBT (RR, 0.91; 95% CI, 0.84-0.98), and cancer detection increased from 3.7 with DM to 5.3 with DBT (RR, 1.42; 95% CI, 1.23-1.64). Women aged 50 to 79 years with scattered fibroglandular density also had improved recall and cancer detection rates with DBT. Women aged 40 to 49 years with scattered fibroglandular density and women aged 50 to 79 years with almost entirely fatty breasts benefited from improved recall rates without change in cancer detection rates. No improvements in recall or cancer detection rates were observed in women with extremely dense breasts on subsequent examinations for any age group., Conclusions and Relevance: This study found that improvements in recall and cancer detection rates with DBT were greatest on baseline mammograms. On subsequent screening mammograms, the benefits of DBT varied by age and breast density. Women with extremely dense breasts did not benefit from improved recall or cancer detection with DBT on subsequent screening rounds.

Purpose: Women with personal history of breast cancer (PHBC) are currently recommended to receive annual mammography for surveillance of breast cancer recurrence or new primary. However, given issues in accuracy with mammography, there is a need for evolving evidence-based surveillance recommendations with supplemental imaging. In this systematic review, we compiled and compared existing studies that describe the test performance of surveillance breast MRI among women with PHBC., Methods: We searched PubMed and EMBASE using MeSH terms for studies (2000-2019) that described the diagnostic characteristics of breast MRI in women with PHBC. Search results were reviewed and included based on PICOTS criteria; quality of included articles was assessed using QUADAS-2. Meta-analysis of single proportions was conducted for diagnostic characteristics of breast MRI, including tests of heterogeneity., Results: Our review included 11 articles in which unique cohorts were studied, comprised of a total of 8338 women with PHBC and 12,335 breast MRI done for the purpose of surveillance. We predict intervals (PI) for cancer detection rate per 1000 examinations (PI 9-15; I 2  = 10%), recall rate (PI 5-31%; I 2  = 97%), sensitivity (PI 58-95%; I 2  = 47%), specificity (PI 76-97%; I 2  = 97%), and PPV3 (PI 16-40%; I 2  = 44%)., Conclusions: Studies addressing performance of breast MRI are variable and limited in population-based studies. The summary of evidence to date is insufficient to recommend for or against use of breast MRI for surveillance among women with PHBC.

Objective: The impact of mammography screening recall on quality-of-life (QOL) has been studied in women at average risk for breast cancer, but it is unknown whether these effects differ by breast cancer risk level. We used a vignette-based survey to evaluate how women across the spectrum of breast cancer risk perceive the experience of screening recall., Methods: Women participating in mammography or breast MRI screening were recruited to complete a vignette-based survey. Using a numerical rating scale (0-100), women rated QOL for hypothetical scenarios of screening recall, both before and after benign results were known. Lifetime breast cancer risk was calculated using Gail and BRCAPRO risk models. Risk perception, trait anxiety, and breast cancer worry were assessed using validated instruments., Results: The final study cohort included 162 women at low (n = 43, 26%), intermediate (n = 66, 41%), and high-risk (n = 53, 33%). Actual breast cancer risk was not a predictor of QOL for any of the presented scenarios. Across all risk levels, QOL ratings were significantly lower for the period during diagnostic uncertainty compared to after benign results were known (p < 0.05). In multivariable regression analyses, breast cancer worry was a significant predictor of decreased QoL for all screening scenarios while awaiting results, including scenarios with non-invasive imaging alone or with biopsy. High trait anxiety and family history predicted lower QOL scores after receipt of benign test results (p < 0.05)., Conclusions: Women with high trait anxiety and family history may particularly benefit from discussions about the risk of recall when choosing a screening regimen., Competing Interests: Declaration of competing interest JML and KPL receive research support from GE Healthcare. GSG was previously a consultant for GE Healthcare until 2018., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: National patterns of breast imaging in women with a personal history of breast cancer (PHBC) are unknown making evaluation of annual surveillance recommendations a challenge., Objective: To describe variation in use of mammography and breast magnetic resonance imaging (MRI) examinations beginning 6 months after diagnosis among women with PHBC in US community practice. We report on the breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type., Design: Longitudinal study using cross-sectional data., Setting: Breast Cancer Surveillance Consortium breast imaging facilities., Participants: 19,955 women diagnosed between 2005 and 2012 with AJCC stage 0-III incident breast cancer who had 69,386 mammograms and 3,553 breast MRI examinations from January 2005 to September 2013; median follow-up of 37.6 months (interquartile range, 22.1-60.7)., Main Measures: Breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type., Key Results: Among women with a PHBC who received breast imaging, 89.4% underwent mammography alone, 0.8% MRI alone, and 10.3% had both mammography and MRI. About half of mammograms and MRIs were indicated for surveillance vs. diagnostic, with an increase in the proportion of surveillance exams as time from diagnosis increased (mammograms, 45.7% at 1 year to 72.2% after 5 years; MRIs, 54.8% at 1 year to 78.6% after 5 years). In the first post-diagnosis period, 32.8% of women had > 2 breast imaging examinations and of these, 65.8% were less than 6 months apart. During the first 5-year post-diagnosis, the frequency of examinations per year decreased and the interval between examinations shifted towards annual examinations., Conclusion: In women with a PHBC who received post-diagnosis imaging, a third underwent multiple breast imaging examinations per year during the first 2-year post-diagnosis despite recommendations for annual exams. As time since diagnosis increases, imaging indication shifts from diagnostic to surveillance.

Background There is lack of consensus regarding the use of breast MRI for routine surveillance for second breast cancer events in women with a personal history of breast cancer. Purpose To compare performance of surveillance mammography with breast MRI. Materials and Methods This observational cohort study used prospectively collected data and included 13 266 women age 18 years and older (mean age, 60 years ± 13) with stage 0-III breast cancer who underwent 33 938 mammographic examinations and 2506 breast MRI examinations from 2005 to 2012 in the Breast Cancer Surveillance Consortium. Women were categorized into two groups: mammography alone ( n = 11 745) or breast MRI ( n = 1521). Performance measures were calculated by using end-of-day assessment and occurrence of second breast cancer events within 1 year of imaging. Logistic regression was used to compare performance for breast MRI versus mammography alone, adjusting for women, examination, and primary breast cancer characteristics. Analysis was conducted on a per-examination basis. Results Breast MRI was associated with younger age at diagnosis, chemotherapy, and higher education and income. Raw performance measures for breast MRI versus mammography were as follows, respectively: cancer detection rates, 10.8 (95% confidence interval [CI]: 6.7, 14.8) versus 8.2 (95% CI: 7.3, 9.2) per 1000 examinations; sensitivity, 61.4% (27 of 44; 95% CI: 46.5%, 76.2%) versus 70.3% (279 of 397; 95% CI: 65.8%, 74.8%); and biopsy rate, 10.1% (253 of 2506; 95% CI: 8.9%, 11.3%) versus 4.0% (1343 of 33 938; 95% CI: 3.7%, 4.2%). In multivariable models, breast MRI was associated with higher biopsy rate (odds ratio [OR], 2.2; 95% CI: 1.9, 2.7; P < .001) and cancer detection rate (OR, 1.7; 95% CI: 1.1, 2.7; P = .03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI: 0.4, 2.9; P = .84) or interval cancer rate (OR, 1.1; 95% CI: 0.6, 2.2; P = .70). Conclusion Comparison of the performance of surveillance breast MRI with mammography must account for patient characteristics. Whereas breast MRI leads to higher biopsy and cancer detection rates, there were no significant differences in sensitivity or interval cancers compared with mammography. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Newell in this issue.

Purpose: To evaluate the impact of double reading automated breast ultrasound (ABUS) when added to full field digital mammography (FFDM) or digital breast tomosynthesis (DBT) for breast cancer screening., Methods: From April 2014 to June 2015, 124 women with dense breasts and intermediate to high breast cancer risk were recruited for screening with FFDM, DBT, and ABUS. Readers used FFDM and DBT in clinical practice and received ABUS training prior to study initiation. FFDM or DBT were first interpreted alone by two independent readers and then with ABUS. All recalled women underwent diagnostic workup with at least one year of follow-up. Recall rates were compared using the sign test; differences in outcomes were evaluated using Fisher's exact test., Results: Of 121 women with complete follow-up, all had family (35.5%) or personal (20.7%) history of breast cancer, or both (43.8%). Twenty-four women (19.8%) were recalled by at least one modality. Recalls increased from 5.0% to 13.2% (p = 0.002) when ABUS was added to FFDM and from 3.3% to 10.7% (p = 0.004) when ABUS was added to DBT. Findings recalled by both readers were more likely to result in a recommendation for short term follow-up imaging or tissue biopsy compared to findings recalled by only one reader (100% vs. 42.1%, p = 0.041). The cancer detection rate was 8.3 per 1000 screens (1/121); mode of detection: FFDM and DBT., Conclusions: Adding ABUS significantly increased the recall rate of both FFDM and DBT screening. Double reading of ABUS during early phase adoption may reduce false positive recalls., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: Whole-breast ultrasonography has been advocated to supplement screening mammography to improve outcomes in women with dense breasts., Objective: To determine the performance of screening mammography plus screening ultrasonography compared with screening mammography alone in community practice., Design, Setting, and Participants: Observational cohort study. Two Breast Cancer Surveillance Consortium registries provided prospectively collected data on screening mammography with vs without same-day breast ultrasonography from January 1, 2000, to December 31, 2013. The dates of analysis were March 2014 to December 2018. A total of 6081 screening mammography plus same-day screening ultrasonography examinations in 3386 women were propensity score matched 1:5 to 30 062 screening mammograms without screening ultrasonography in 15 176 women from a sample of 113 293 mammograms. Exclusion criteria included a personal history of breast cancer and self-reported breast symptoms., Exposures: Screening mammography with vs without screening ultrasonography., Main Outcomes and Measures: Cancer detection rate and rates of interval cancer, false-positive biopsy recommendation, short-interval follow-up, and positive predictive value of biopsy recommendation were estimated and compared using log binomial regression., Results: Screening mammography with vs without ultrasonography examinations was performed more often in women with dense breasts (74.3% [n = 4317 of 5810] vs 35.9% [n = 39 928 of 111 306] in the overall sample), in women who were younger than 50 years (49.7% [n = 3022 of 6081] vs 31.7% [n = 16 897 of 112 462]), and in women with a family history of breast cancer (42.9% [n = 2595 of 6055] vs 15.0% [n = 16 897 of 112 462]). While 21.4% (n = 1154 of 5392) of screening ultrasonography examinations were performed in women with high or very high (≥2.50%) Breast Cancer Surveillance Consortium 5-year risk scores, 53.6% (n = 2889 of 5392) had low or average (<1.67%) risk. Comparing mammography plus ultrasonography with mammography alone, the cancer detection rate was similar at 5.4 vs 5.5 per 1000 screens (adjusted relative risk [RR], 1.14; 95% CI, 0.76-1.68), as were interval cancer rates at 1.5 vs 1.9 per 1000 screens (RR, 0.67; 95% CI, 0.33-1.37). The false-positive biopsy rates were significantly higher at 52.0 vs 22.2 per 1000 screens (RR, 2.23; 95% CI, 1.93-2.58), as was short-interval follow-up at 3.9% vs 1.1% (RR, 3.10; 95% CI, 2.60-3.70). The positive predictive value of biopsy recommendation was significantly lower at 9.5% vs 21.4% (RR, 0.50; 95% CI, 0.35-0.71)., Conclusions and Relevance: In a relatively young population of women at low, intermediate, and high breast cancer risk, these results suggest that the benefits of supplemental ultrasonography screening may not outweigh associated harms.

After years of development, the RadLex terminology contains a large set of controlled terms for the radiology domain, but gaps still exist. We developed a data-driven approach to discover new terms for RadLex by mining a large corpus of radiology reports using natural language processing (NLP) methods. Our system, developed for mammography, discovers new candidate terms by analyzing noun phrases in free-text reports to extend the mammography part of RadLex. Our NLP system extracts noun phrases from free-text mammography reports and classifies these noun phrases as "Has Candidate RadLex Term" or "Does Not Have Candidate RadLex Term." We tested the performance of our algorithm using 100 free-text mammography reports. An expert radiologist determined the true positive and true negative RadLex candidate terms. We calculated precision/positive predictive value and recall/sensitivity metrics to judge the system's performance. Finally, to identify new candidate terms for enhancing RadLex, we applied our NLP method to 270,540 free-text mammography reports obtained from three academic institutions. Our method demonstrated precision/positive predictive value of 0.77 (159/206 terms) and a recall/sensitivity of 0.94 (159/170 terms). The overall accuracy of the system is 0.80 (235/293 terms). When we ran our system on the set of 270,540 reports, it found 31,800 unique noun phrases that are potential candidates for RadLex. Our data-driven approach to mining radiology reports can identify new candidate terms for expanding the breast imaging lexicon portion of RadLex and may be a useful approach for discovering new candidate terms from other radiology domains.

Purpose: To identify predictors of poor mammography surveillance outcomes based on clinico-pathologic features., Methods: This study was HIPAA compliant and IRB approved. We performed an electronic medical record review for a cohort of women with American Joint Committee on Cancer (AJCC) Stage I or II invasive breast cancer treated with breast conservation therapy who developed subsequent in-breast treatment recurrence (IBTR) or contralateral breast cancer (CBC). Poor surveillance outcome was defined as second breast cancer not detected by surveillance mammography, including interval cancers (diagnosed within 365 days of surveillance mammogram with negative results) and clinically detected cancers (diagnosed without a surveillance mammogram in the preceding 365 days). Univariate and multivariate logistic regression were performed to identify predictors of poor mammography surveillance outcome, including patient and primary tumor characteristics, breast density, mode of primary tumor detection, and time to second cancer diagnosis., Results: 164 women met inclusion criteria (65 with IBTR, 99 with CBC); 124 had screen-detected second cancers. On univariate analysis, poor surveillance outcome (n = 40) was associated with age at primary cancer diagnosis < 50 years (p < 0.0001), AJCC stage II primary cancers (p = 0.007), and heterogeneously or extremely dense breasts (p = 0.04). On multivariate analysis, age < 50 years at primary breast cancer diagnosis remained a significant predictor of poor surveillance outcome (p = 0.001)., Conclusion: Women younger than age 50 at primary breast cancer diagnosis are at risk of poor surveillance mammography outcomes, and may be appropriate candidates for more intensive clinical and imaging surveillance.

Purpose The aim of the current study was to characterize the risk of interval invasive second breast cancers within 5 years of primary breast cancer treatment. Methods We examined 65,084 surveillance mammograms from 18,366 women with a primary breast cancer diagnosis of unilateral ductal carcinoma in situ or stage I to III invasive breast carcinoma performed from 1996 to 2012 in the Breast Cancer Surveillance Consortium. Interval invasive breast cancer was defined as ipsilateral or contralateral cancer diagnosed within 1 year after a negative surveillance mammogram. Discrete-time survival models-adjusted for all covariates-were used to estimate the probability of interval invasive cancer, given the risk factors for each surveillance round, and aggregated across rounds to estimate the 5-year cumulative probability of interval invasive cancer. Results We observed 474 surveillance-detected cancers-334 invasive and 140 ductal carcinoma in situ-and 186 interval invasive cancers which yielded a cancer detection rate of 7.3 per 1,000 examinations (95% CI, 6.6 to 8.0) and an interval invasive cancer rate of 2.9 per 1,000 examinations (95% CI, 2.5 to 3.3). Median cumulative 5-year interval cancer risk was 1.4% (interquartile range, 0.8% to 2.3%; 10 th to 90th percentile range, 0.5% to 3.7%), and 15% of women had ≥ 3% 5-year interval invasive cancer risk. Cumulative 5-year interval cancer risk was highest for women with estrogen receptor- and progesterone receptor-negative primary breast cancer (2.6%; 95% CI, 1.7% to 3.5%), interval cancer presentation at primary diagnosis (2.2%; 95% CI, 1.5% to 2.9%), and breast conservation without radiation (1.8%; 95% CI, 1.1% to 2.4%). Conclusion Risk of interval invasive second breast cancer varies across women and is influenced by characteristics that can be measured at initial diagnosis, treatment, and imaging. Risk prediction models that evaluate the risk of cancers not detected by surveillance mammography should be developed to inform discussions of tailored surveillance.

Objective: The purposes of this article are to provide an overview of current and emerging practices in radiologist communications with both referring physicians and patients across the breast cancer care continuum; to highlight areas in which radiologist-driven communications can improve value in breast cancer screening, diagnosis, and treatment; and describe how the integrative reporting and consultative practices of breast imagers can serve as models of higher-value patient-centered care in other radiology subspecialties., Conclusion: The traditional radiology report will eventually no longer be viewed as the sole consultation by radiologists but instead act as a starting point for more detailed communications between radiologists and both patients and physicians. The value-creating practices of breast imagers can be used as a road map for similar practices across other radiologic specialties, similar to the use of BI-RADS as a road map for structured breast imaging reporting.

Purpose To establish performance benchmarks for modern screening digital mammography and assess performance trends over time in U.S. community practice. Materials and Methods This HIPAA-compliant, institutional review board-approved study measured the performance of digital screening mammography interpreted by 359 radiologists across 95 facilities in six Breast Cancer Surveillance Consortium (BCSC) registries. The study included 1 682 504 digital screening mammograms performed between 2007 and 2013 in 792 808 women. Performance measures were calculated according to the American College of Radiology Breast Imaging Reporting and Data System, 5th edition, and were compared with published benchmarks by the BCSC, the National Mammography Database, and performance recommendations by expert opinion. Benchmarks were derived from the distribution of performance metrics across radiologists and were presented as 50th (median), 10th, 25th, 75th, and 90th percentiles, with graphic presentations using smoothed curves. Results Mean screening performance measures were as follows: abnormal interpretation rate (AIR), 11.6 (95% confidence interval [CI]: 11.5, 11.6); cancers detected per 1000 screens, or cancer detection rate (CDR), 5.1 (95% CI: 5.0, 5.2); sensitivity, 86.9% (95% CI: 86.3%, 87.6%); specificity, 88.9% (95% CI: 88.8%, 88.9%); false-negative rate per 1000 screens, 0.8 (95% CI: 0.7, 0.8); positive predictive value (PPV) 1, 4.4% (95% CI: 4.3%, 4.5%); PPV2, 25.6% (95% CI: 25.1%, 26.1%); PPV3, 28.6% (95% CI: 28.0%, 29.3%); cancers stage 0 or 1, 76.9%; minimal cancers, 57.7%; and node-negative invasive cancers, 79.4%. Recommended CDRs were achieved by 92.1% of radiologists in community practice, and 97.1% achieved recommended ranges for sensitivity. Only 59.0% of radiologists achieved recommended AIRs, and only 63.0% achieved recommended levels of specificity. Conclusion The majority of radiologists in the BCSC surpass cancer detection recommendations for screening mammography; however, AIRs continue to be higher than the recommended rate for almost half of radiologists interpreting screening mammograms. © RSNA, 2016 Online supplemental material is available for this article.

Purpose To establish contemporary performance benchmarks for diagnostic digital mammography with use of recent data from the Breast Cancer Surveillance Consortium (BCSC). Materials and Methods Institutional review board approval was obtained for active or passive consenting processes or to obtain a waiver of consent to enroll participants, link data, and perform analyses. Data were obtained from six BCSC registries (418 radiologists, 92 radiology facilities). Mammogram indication and assessments were prospectively collected for women undergoing diagnostic digital mammography and linked with cancer diagnoses from state cancer registries. The study included 401 548 examinations conducted from 2007 to 2013 in 265 360 women. Results Overall diagnostic performance measures were as follows: cancer detection rate, 34.7 per 1000 (95% confidence interval [CI]: 34.1, 35.2); abnormal interpretation rate, 12.6% (95% CI: 12.5%, 12.7%); positive predictive value (PPV) of a biopsy recommendation (PPV 2 ), 27.5% (95% CI: 27.1%, 27.9%); PPV of biopsies performed (PPV 3 ), 30.4% (95% CI: 29.9%, 30.9%); false-negative rate, 4.8 per 1000 (95% CI: 4.6, 5.0); sensitivity, 87.8% (95% CI: 87.3%, 88.4%); and specificity, 90.5% (95% CI: 90.4%, 90.6%). Among cancers detected, 63.4% were stage 0 or 1 cancers, 45.6% were minimal cancers, the mean size of invasive cancers was 21.2 mm, and 69.6% of invasive cancers were node negative. Performance metrics varied widely across diagnostic indications, with cancer detection rate (64.5 per 1000) and abnormal interpretation rate (18.7%) highest for diagnostic mammograms obtained to evaluate a breast problem with a lump. Compared with performance during the screen-film mammography era, diagnostic digital performance showed increased abnormal interpretation and cancer detection rates and decreasing PPVs, with less than 70% of radiologists within acceptable ranges for PPV 2 and PPV 3 . Conclusion These performance measures can serve as national benchmarks that may help transform the marked variation in radiologists' diagnostic performance into targeted quality improvement efforts. © RSNA, 2017 Online supplemental material is available for this article.

Objective: Current clinical guidelines are consistent in supporting annual mammography for women after treatment of primary breast cancer. Surveillance imaging beyond standard digital mammography, including digital breast tomosynthesis (DBT), breast ultrasound, and MRI, may improve outcomes. This article reviews the evidence on the performance and effectiveness of breast imaging modalities available for surveillance after treatment of sporadic unilateral primary breast cancer and identifies additional factors to be considered when selecting an imaging surveillance regimen., Conclusion: Evidence review supports the use of mammography for surveillance after primary breast cancer treatment. Variability exists in guideline recommendations for surveillance initiation, interval, and cessation. DBT offers the most promise as a potential modality to replace standard digital mammography as a front-line surveillance test; a single published study to date has shown a significant decrease in recall rates compared with standard digital mammography alone. Most guidelines do not support the use of whole-breast ultrasound in breast cancer surveillance, and further studies are needed to define the characteristics of women who may benefit from MRI surveillance. The emerging evidence about surveillance imaging outcomes suggests that additional factors, including patient and imaging characteristics, tumor biology and gene expression profile, and choice of treatment, warrant consideration in selecting personalized posttreatment imaging surveillance regimens.

Objective: The purpose of this study is to determine whether primary care physicians were influenced by their own specialty society's mammography screening recommendations after the 2009 U.S. Preventive Services Task Force's (USPSTF) revised recommendations were released., Materials and Methods: We performed an analysis of cross-sectional nationally representative data for 2007-2012 from the National Ambulatory Medical Care Survey (NAMCS). All office-based preventive services visits for women 40 years old or older were included. Multivariate regression analyses were used to identify changes over time in the mammography referral rate per 1000 visits by physician specialty, adjusting for patient- and office-level covariates. All analyses were weighted to account for the multistage probability sampling design of NAMCS., Results: Our analysis represented an average of 35,947,290 office visits per year. Overall, between 2007-2008 and 2011-2012, mammography referral rates (per 1000 visits) decreased from 285 to 215 referrals (-25.0% adjusted change; p = 0.006). The largest decrease was among family physicians (from 230 to 128; -49.0% adjusted change; p < 0.001), followed by internal medicine physicians (from 135 to 79; -45.8% adjusted change; p = 0.038). No statistically significant change was noted among obstetricians and gynecologists over time (from 476 to 419; -14.4% adjusted change; p = 0.23)., Discussion: Family and internal medicine physicians, whose societies adhered to 2009 USPSTF recommendations for biennial screening starting at age 50 years, showed statistically significant decreases in mammography referral rates over time. Obstetricians and gynecologists, whose society continued to recommend annual screening starting at age 40 years, showed no statistically significant change in mammography referral rates over time. Physicians may be influenced by their own society's recommendations, which may influence their shared decision-making discussions with patients.

Objective: Examining the comparative effectiveness of adding tomosynthesis to mammography screening in the United States would help key stakeholders, including physicians and policy makers, guide shared decision-making and recommendations for routine breast cancer screening., Conclusion: More robust data from U.S.-based longitudinal observational studies, clinical trials, or both are needed, along with the use of validated microsimulation models, before clinical- and cost-effectiveness of tomosynthesis screening versus mammography screening can be fully characterized.

Radiologists, as administrators and interpreters of screening mammography, are considered by some to be major contributors to the potential harms of screening, including overdiagnosis and overtreatment. In this article, we outline current efforts within the breast imaging community toward mitigating screening harms, including the widespread adoption of tomosynthesis and potentially adjusting screening frequency and thresholds for image-guided breast biopsy. However, the emerging field of breast radiomics may offer the greatest promise for reducing overdiagnosis by identifying imaging-based biomarkers strongly associated with tumor biology, and therefore helping prevent the harms of unnecessary treatment for indolent cancers., (Copyright © 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Background: Earlier detection of second breast cancers after primary breast cancer (PBC) treatment improves survival, yet mammography is less accurate in women with prior breast cancer. The purpose of this study was to examine women presenting clinically with second breast cancers after negative surveillance mammography (interval cancers), and to estimate the five-year risk of interval-invasive second cancers for women with varying risk profiles., Methods: We evaluated a prospective cohort of 15 114 women with 47 717 surveillance mammograms diagnosed with stage 0-II unilateral PBC from 1996 through 2008 at facilities in the Breast Cancer Surveillance Consortium. We used discrete time survival models to estimate the association between odds of an interval-invasive second breast cancer and candidate predictors, including demographic, PBC, and imaging characteristics. All statistical tests were two-sided., Results: The cumulative incidence of second breast cancers after five years was 54.4 per 1000 women, with 325 surveillance-detected and 138 interval-invasive second breast cancers. The five-year risk of interval-invasive second cancer for women with referent category characteristics was 0.60%. For women with the most and least favorable profiles, the five-year risk ranged from 0.07% to 6.11%. Multivariable modeling identified grade II PBC (odds ratio [OR] = 1.95, 95% confidence interval [CI] = 1.15 to 3.31), treatment with lumpectomy without radiation (OR = 3.27, 95% CI = 1.91 to 5.62), interval PBC presentation (OR = 2.01, 95% CI 1.28 to 3.16), and heterogeneously dense breasts on mammography (OR = 1.54, 95% CI = 1.01 to 2.36) as independent predictors of interval-invasive second breast cancers., Conclusions: PBC diagnosis and treatment characteristics contribute to variation in subsequent-interval second breast cancer risk. Consideration of these factors may be useful in developing tailored post-treatment imaging surveillance plans., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

There are potential benefits and harms of screening ultrasound (US) to supplement mammographic screening of women with dense breast tissue. We conducted a comprehensive literature review of studies assessing the efficacy of screening US to supplement mammography among women with dense breasts. From a total of 189 peer-reviewed publications on the performance of screening US, 12 studies were relevant to our analysis. The reporting of breast cancer risk factors varied across studies; however, the study populations tended to be at greater than average risk for developing breast cancer. Overall, US detected an additional 0.3-7.7 cancers per 1000 examinations (median, 4.2) and was associated with an additional 11.7-106.6 biopsies per 1000 examinations (median, 52.2). Significant improvements in cancer detection in dense breasts have been achieved with the transition from film to digital mammography. Thus adjunctive screening with ultrasound should be considered in the context of current screening mammography performance. Clinicians should discuss breast density as 1 of several important breast cancer risk factors, consider the potential harms of adjunctive screening, and arrive at a shared decision consistent with each woman's preferences and values., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Current clinical guidelines recommend earlier, more intensive breast cancer screening with both magnetic resonance imaging (MRI) and mammography for women with breast cancer susceptibility gene (BRCA) mutations. Unspecified details of screening schedules are a challenge for implementing guidelines., Methods: A Markov Monte Carlo computer model was used to simulate screening in asymptomatic women who were BRCA1 and BRCA2 mutation carriers. Three dual-modality strategies were compared with digital mammography (DM) alone: 1) DM and MRI alternating at 6-month intervals beginning at age 25 years (Alt25), 2) annual MRI beginning at age 25 years with alternating DM added at age 30 years (MRI25/Alt30), and 3) DM and MRI alternating at 6-month intervals beginning at age 30 years (Alt30). Primary outcomes were quality-adjusted life years (QALYs), lifetime costs (in 2010 US dollars), and incremental cost-effectiveness (dollars per QALY gained). Additional outcomes included potential harms of screening, and lifetime costs stratified into component categories (screening and diagnosis, treatment, mortality, and patient time costs)., Results: All 3 dual-modality screening strategies increased QALYs and costs. Alt30 screening had the lowest incremental costs per additional QALY gained (BRCA1, $74,200 per QALY; BRCA2, $215,700 per QALY). False-positive test results increased substantially with dual-modality screening and occurred more frequently in BRCA2 carriers. Downstream savings in both breast cancer treatment and mortality costs were outweighed by increases in up-front screening and diagnosis costs. The results were influenced most by estimates of breast cancer risk and MRI costs., Conclusions: Alternating MRI and DM screening at 6-month intervals beginning at age 30 years was identified as a clinically effective approach to applying current guidelines, and was more cost-effective in BRCA1 gene mutation carriers compared with BRCA2 gene mutation carriers., (Copyright © 2012 American Cancer Society.)

Background: Although breast cancer screening with mammography and magnetic resonance imaging (MRI) is recommended for breast cancer-susceptibility gene (BRCA) mutation carriers, there is no current consensus on the optimal screening regimen., Methods: The authors used a computer simulation model to compare 6 annual screening strategies (film mammography [FM], digital mammography [DM], FM and magnetic resonance imaging [MRI] or DM and MRI contemporaneously, and alternating FM/MRI or DM/MRI at 6-month intervals) beginning at ages 25 years, 30 years, 35 years, and 40 years, and 2 strategies of annual MRI with delayed alternating DM/FM versus clinical surveillance alone. Strategies were evaluated without and with mammography-induced breast cancer risk using 2 models of excess relative risk. Input parameters were obtained from the medical literature, publicly available databases, and calibration., Results: Without radiation risk effects, alternating DM/MRI starting at age 25 years provided the highest life expectancy (BRCA1, 72.52 years, BRCA2, 77.63 years). When radiation risk was included, a small proportion of diagnosed cancers was attributable to radiation exposure (BRCA1, <2%; BRCA2, <4%). With radiation risk, alternating DM/MRI at age 25 years or annual MRI at age 25 years/delayed alternating DM at age 30 years was the most effective, depending on the radiation risk model used. Alternating DM/MRI starting at age 25 years also produced the highest number of false-positive screens per woman (BRCA1, 4.5 BRCA2, 8.1)., Conclusions: Annual MRI at age 25 years/delayed alternating DM at age 30 years is probably the most effective screening strategy in BRCA mutation carriers. Screening benefits, associated risks, and personal acceptance of false-positive results should be considered in choosing the optimal screening strategy for individual women., (Copyright © 2011 American Cancer Society.)

Purpose: To evaluate the effect of incorporating radiation risk into microsimulation (first-order Monte Carlo) models for breast and lung cancer screening to illustrate effects of including radiation risk on patient outcome projections., Materials and Methods: All data used in this study were derived from publicly available or deidentified human subject data. Institutional review board approval was not required. The challenges of incorporating radiation risk into simulation models are illustrated with two cancer screening models (Breast Cancer Model and Lung Cancer Policy Model) adapted to include radiation exposure effects from mammography and chest computed tomography (CT), respectively. The primary outcome projected by the breast model was life expectancy (LE) for BRCA1 mutation carriers. Digital mammographic screening beginning at ages 25, 30, 35, and 40 years was evaluated in the context of screenings with false-positive results and radiation exposure effects. The primary outcome of the lung model was lung cancer-specific mortality reduction due to annual screening, comparing two diagnostic CT protocols for lung nodule evaluation. The Metropolis-Hastings algorithm was used to estimate the mean values of the results with 95% uncertainty intervals (UIs)., Results: Without radiation exposure effects, the breast model indicated that annual digital mammography starting at age 25 years maximized LE (72.03 years; 95% UI: 72.01 years, 72.05 years) and had the highest number of screenings with false-positive results (2.0 per woman). When radiation effects were included, annual digital mammography beginning at age 30 years maximized LE (71.90 years; 95% UI: 71.87 years, 71.94 years) with a lower number of screenings with false-positive results (1.4 per woman). For annual chest CT screening of 50-year-old females with no follow-up for nodules smaller than 4 mm in diameter, the lung model predicted lung cancer-specific mortality reduction of 21.50% (95% UI: 20.90%, 22.10%) without radiation risk and 17.75% (95% UI: 16.97%, 18.41%) with radiation risk., Conclusion: Because including radiation exposure risk can influence long-term projections from simulation models, it is important to include these risks when conducting modeling-based assessments of diagnostic imaging., (© RSNA, 2012.)

Purpose: To evaluate the clinical effectiveness and cost-effectiveness of screening strategies in which MR imaging and screen-film mammography were used, alone and in combination, in women with BRCA1 mutations., Materials and Methods: Because this study did not involve primary data collection from individual patients, institutional review board approval was not needed. By using a simulation model, we compared three annual screening strategies for a cohort of 25-year-old BRCA1 mutation carriers, as follows: (a) screen-film mammography, (b) MR imaging, and (c) combined MR imaging and screen-film mammography (combined screening). The model was used to estimate quality-adjusted life-years (QALYs) and lifetime costs. Incremental cost-effectiveness ratios were calculated. Input parameters were obtained from the medical literature, existing databases, and calibration. Costs (2007 U.S. dollars) and quality-of-life adjustments were derived from Medicare reimbursement rates and the medical literature. Sensitivity analysis was performed to evaluate the effect of uncertainty in parameter estimates on model results., Results: In the base-case analysis, annual combined screening was most effective (44.62 QALYs), and had the highest cost ($110973), followed by annual MR imaging alone (44.50 QALYs, $108641), and annual mammography alone (44.46 QALYs, $100336). Adding annual MR imaging to annual mammographic screening cost $69125 for each additional QALY gained. Sensitivity analysis indicated that, when the screening MR imaging cost increased to $960 (base case, $577), or breast cancer risk by age 70 years decreased below 58% (base case, 65%), or the sensitivity of combined screening decreased below 76% (base case, 94%), the cost of adding MR imaging to mammography exceeded $100000 per QALY., Conclusion: Annual combined screening provides the greatest life expectancy and is likely cost-effective when the value placed on gaining an additional QALY is in the range of $50000-$100000., Supplemental Material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091086/-/DC1., ((c) RSNA, 2010)

Rationale and Objectives: Breast magnetic resonance imaging (MRI) is increasingly being added to mammography for screening asymptomatic women at increased risk of breast cancer. Because the direction and extent of correlation between mammography and MRI could potentially result in over- or underestimation of the diagnostic gain related to using MRI as an adjunct to mammographic screening, we performed an analysis to evaluate the extent of correlation between mammography and MRI., Materials and Methods: We reviewed the published literature to identify multimodality breast cancer screening studies reporting the sensitivity of mammography and MRI, alone and in combination, for breast cancer diagnosis. After calculating the expected sensitivity of combined mammography and MRI under conditions of test independence (no correlation), we compared the calculated and observed sensitivities for combined mammography and MRI. We then calculated correlation coefficients for mammography and MRI., Results: Seven studies of multimodality screening in women at increased risk of developing breast cancer were included for analysis. Of these studies, the correlation between film mammography and MRI was positive in three studies, negative in two studies, and not identified in two studies. The calculated correlation coefficients ranged from -0.38 to 0.18. In six of seven studies, the 95% confidence interval for the correlation coefficient included 0.0, indicating no significant correlation., Conclusions: Evidence from published trials of multimodality breast cancer screening identified no statistically significant correlation between film mammography and MRI. Using both tests for breast cancer screening is likely to improve the early detection of breast cancer in women at increased risk.

PurposeThe aim of this study was to develop a prioritization strategy for scheduling immediate screening mammographic interpretation and possible diagnostic evaluation.MethodsA population-based cohort with screening mammograms performed from 2012 to 2020 at 126 radiology facilities from 7 Breast Cancer Surveillance Consortium registries was identified. Classification trees identified combinations of clinical history (age, BI-RADS® density, time since prior mammogram, history of false-positive recall or biopsy result), screening modality (digital mammography, digital breast tomosynthesis), and facility characteristics (profit status, location, screening volume, practice type, academic affiliation) that grouped screening mammograms by recall rate, with ≥12/100 considered high and ≥16/100 very high. An efficiency ratio was estimated as the percentage of recalls divided by the percentage of mammograms.ResultsThe study cohort included 2,674,051 screening mammograms in 925,777 women, with 235,569 recalls. The most important predictor of recall was time since prior mammogram, followed by age, history of false-positive recall, breast density, history of benign biopsy, and screening modality. Recall rates were very high for baseline mammograms (21.3/100; 95% confidence interval, 19.7-23.0) and high for women with ≥5 years since prior mammogram (15.1/100; 95% confidence interval, 14.3-16.1). The 9.2% of mammograms in subgroups with very high and high recall rates accounted for 19.2% of recalls, an efficiency ratio of 2.1 compared with a random approach. Adding women

The COVID-19 pandemic disrupted breast cancer screening and diagnostic imaging in the United States. We sought to evaluate how medical facilities prioritized breast imaging services during periods of reduced capacity or upon re-opening after closures. In fall 2020, we surveyed 77 breast imaging facilities within the Breast Cancer Surveillance Consortium in the United States. The survey ascertained the pandemic's impact on clinical practices during March-September 2020. Nearly all facilities (97%) reported closing or operating at reduced capacity at some point during this period. All facilities were open by August 2020, though 14% were still operating at reduced capacity in September 2020. During periods of re-opening or reduced capacity, 93% of facilities reported prioritizing diagnostic breast imaging over breast cancer screening. For diagnostic imaging, facilities prioritized based on rescheduling canceled appointments (89%), specific indication for diagnostic imaging (89%), patient demand (84%), individual characteristics and risk factors (77%), and time since last imaging examination (72%). For screening mammography, facilities prioritized based on rescheduled cancelations (96%), patient demand (83%), individual characteristics and risk factors (73%), and time since last mammogram (71%). For biopsy services, more than 90% of facilities reported prioritization based on rescheduling of canceled exams, patient demand, patient characteristics and risk factors and level of suspicion on imaging. The observed patterns from this large and geographically diverse sample of facilities in the United States indicate that multiple factors were commonly used to prioritize breast imaging services during periods of reduced capacity.

BackgroundAdvanced breast cancer is an outcome used to evaluate screening effectiveness. The advanced cancer definition resulting in the best discrimination of breast cancer death has not been studied in a breast imaging population.MethodsA total of 52 496 women aged 40-79 years participating in the Breast Cancer Surveillance Consortium diagnosed with invasive cancer were staged using the 8th edition of American Joint Committee on Cancer (AJCC) anatomic and prognostic pathologic systems and Tomosynthesis Mammographic Imaging Screening Trial (TMIST) tumor categories. We calculated the area under the receiver operating characteristic curve for predicting 5-year breast cancer death and the sensitivity and specificity for predicting 5-year breast cancer death for 3 advanced cancer classifications: anatomic stage IIB or higher, prognostic pathologic stage IIA or higher, and TMIST advanced cancer.ResultsThe area under the receiver operating characteristic curves for predicting 5-year breast cancer death for AJCC anatomic stage, AJCC prognostic pathologic stage, and TMIST tumor categories were 0.826 (95% confidence interval [CI] = 0.817 to 0.835), 0.856 (95% CI = 0.846 to 0.866), and 0.789 (95% CI = 0.780 to 0.797), respectively. AJCC prognostic pathologic stage had statistically significantly better discrimination than AJCC anatomic stage (difference = 0.030, bootstrap 95% CI = 0.024 to 0.037) and TMIST tumor categories (difference = 0.067, bootstrap 95% CI = 0.059 to 0.075). The sensitivity and specificity for predicting 5-year breast cancer death for AJCC anatomic stage IIB or higher, AJCC prognostic pathologic stage IIA or higher, and TMIST advanced cancer were 72.6%, 76.7%, and 96.1%; and 78.9%, 81.6%, and 41.1%, respectively.ConclusionsDefining advanced cancer as AJCC prognostic pathologic stage IIA or higher most accurately predicts breast cancer death. Use of this definition by investigators will facilitate comparing breast cancer screening effectiveness studies.

ObjectiveWe sought to identify and characterize examinations in women with a personal history of breast cancer likely performed for asymptomatic surveillance.MethodsWe included surveillance mammograms (1997-2017) in asymptomatic women with a personal history of breast cancer diagnosed at age ≥18 years (1996-2016) from 103 Breast Cancer Surveillance Consortium facilities. We examined facility-level variability in examination indication. We modeled the relative risk (RR) and 95% confidence intervals (CIs) at the examination level of a (1) nonscreening indication and (2) surveillance interval ≤9 months using Poisson regression with fixed effects for facility, stage, diagnosis age, surgery, examination year, and time since diagnosis.ResultsAmong 244,855 surveillance mammograms, 69.5% were coded with a screening indication, 12.7% short-interval follow-up, and 15.3% as evaluation of a breast problem. Within a facility, the proportion of examinations with a screening indication ranged from 6% to 100% (median 86%, interquartile range 79%-92%). Facilities varied the most for examinations in the first 5 years after diagnosis, with 39.4% of surveillance mammograms having a nonscreening indication. Within a facility, breast conserving surgery compared with mastectomy (RR = 1.64; 95% CI = 1.60-1.68) and less time since diagnosis (1 year versus 5 years; RR = 1.69; 95% CI = 1.66-1.72; 3 years versus 5 years = 1.20; 95% CI = 1.18-1.23) were strongly associated with a nonscreening indication with similar results for ≤9-month surveillance interval. Screening indication and >9-month surveillance intervals were more common in more recent years.ConclusionVariability in surveillance indications across facilities in the United States supports including indications beyond screening in studies evaluating surveillance mammography effectiveness and demonstrates the need for standardization.

PurposeTo evaluate comparative associations of breast magnetic resonance imaging (MRI) background parenchymal enhancement (BPE) and mammographic breast density with subsequent breast cancer risk.Patients and methodsWe examined women undergoing breast MRI in the Breast Cancer Surveillance Consortium from 2005 to 2015 (with one exam in 2000) using qualitative BPE assessments of minimal, mild, moderate, or marked. Breast density was assessed on mammography performed within 5 years of MRI. Among women diagnosed with breast cancer, the first BPE assessment was included if it was more than 3 months before their first diagnosis. Breast cancer risk associated with BPE was estimated using Cox proportional hazards regression.ResultsAmong 4,247 women, 176 developed breast cancer (invasive, n = 129; ductal carcinoma in situ,n = 47) over a median follow-up time of 2.8 years. More women with cancer had mild, moderate, or marked BPE than women without cancer (80% v 66%, respectively). Compared with minimal BPE, increasing BPE levels were associated with significantly increased cancer risk (mild: hazard ratio [HR], 1.80; 95% CI, 1.12 to 2.87; moderate: HR, 2.42; 95% CI, 1.51 to 3.86; and marked: HR, 3.41; 95% CI, 2.05 to 5.66). Compared with women with minimal BPE and almost entirely fatty or scattered fibroglandular breast density, women with mild, moderate, or marked BPE demonstrated elevated cancer risk if they had almost entirely fatty or scattered fibroglandular breast density (HR, 2.30; 95% CI, 1.19 to 4.46) or heterogeneous or extremely dense breasts (HR, 2.61; 95% CI, 1.44 to 4.72), with no significant interaction (P = .82). Combined mild, moderate, and marked BPE demonstrated significantly increased risk of invasive cancer (HR, 2.73; 95% CI, 1.66 to 4.49) but not ductal carcinoma in situ (HR, 1.48; 95% CI, 0.72 to 3.05).ConclusionBPE is associated with future invasive breast cancer risk independent of breast density. BPE should be considered for risk prediction models for women undergoing breast MRI.

Background Annual surveillance mammography is recommended for women with a personal history of breast cancer. Risk prediction models that estimate mammography failures such as interval second breast cancers could help to tailor surveillance imaging regimens to women's individual risk profiles. Methods In a cohort of women with a history of breast cancer receiving surveillance mammography in the Breast Cancer Surveillance Consortium in 1996-2019, we used Least Absolute Shrinkage and Selection Operator (LASSO)-penalized regression to estimate the probability of an interval second cancer (invasive cancer or ductal carcinoma in situ) in the 1 year after a negative surveillance mammogram. Based on predicted risks from this one-year risk model, we generated cumulative risks of an interval second cancer for the five-year period after each mammogram. Model performance was evaluated using cross-validation in the overall cohort and within race and ethnicity strata. Results In 173 290 surveillance mammograms, we observed 496 interval cancers. One-year risk models were well-calibrated (expected/observed ratio = 1.00) with good accuracy (area under the receiver operating characteristic curve = 0.64). Model performance was similar across race and ethnicity groups. The median five-year cumulative risk was 1.20% (interquartile range 0.93%-1.63%). Median five-year risks were highest in women who were under age 40 or pre- or perimenopausal at diagnosis and those with estrogen receptor-negative primary breast cancers. Conclusions Our risk model identified women at high risk of interval second breast cancers who may benefit from additional surveillance imaging modalities. Risk models should be evaluated to determine if risk-guided supplemental surveillance imaging improves early detection and decreases surveillance failures. [ABSTRACT FROM AUTHOR]

ObjectiveThe purpose of this study was to evaluate concordance between BI-RADS assessments and management recommendations for breast MRI in community practice.Materials and methodsBreast MRI data were collected from four regional Breast Cancer Surveillance Consortium registries from 2005 to 2011 for women who were 18-79 years old. Assessments and recommendations were compared to determine concordance according to BI-RADS guidelines. Concordance was compared by assessment category as well as by year of examination and clinical indication.ResultsIn all, 8283 MRI examinations were included in the analysis. Concordance was highest (93% [2475/2657]) in examinations with a BI-RADS category 2 (benign) assessment. Concordance was also high in examinations with category 1 (negative) (87% [1669/1909]), category 0 (incomplete) (83% [348/417]), category 5 (highly suggestive of malignancy) (83% [208/252]), and category 4 (suspicious) (74% [734/993]) assessments. Examinations with categories 3 (probably benign) and 6 (known biopsy-proven malignancy) assessments had the lowest concordance rates (36% [302/837] and 56% [676/1218], respectively). The most frequent discordant recommendation for a category 3 assessment was routine follow-up. The most frequent discordant recommendation for a category 6 assessment was biopsy. Concordance of assessments and management recommendations differed across clinical indications (p < 0.0001), with the lowest concordance in examinations to assess disease extent.ConclusionBreast MRI BI-RADS management recommendations were most concordant for assessments of negative, incomplete, suspicious, and highly suggestive of malignancy. Lower concordance for assessments of probably benign and known biopsy-proven malignancy and for examinations performed to assess disease extent highlight areas for interventions to improve breast MRI reporting.

Background: There are no consensus guidelines for supplemental breast cancer screening with whole‐breast ultrasound. However, criteria for women at high risk of mammography screening failures (interval invasive cancer or advanced cancer) have been identified. Mammography screening failure risk was evaluated among women undergoing supplemental ultrasound screening in clinical practice compared with women undergoing mammography alone. Methods: A total of 38,166 screening ultrasounds and 825,360 screening mammograms without supplemental screening were identified during 2014–2020 within three Breast Cancer Surveillance Consortium (BCSC) registries. Risk of interval invasive cancer and advanced cancer were determined using BCSC prediction models. High interval invasive breast cancer risk was defined as heterogeneously dense breasts and BCSC 5‐year breast cancer risk ≥2.5% or extremely dense breasts and BCSC 5‐year breast cancer risk ≥1.67%. Intermediate/high advanced cancer risk was defined as BCSC 6‐year advanced breast cancer risk ≥0.38%. Results: A total of 95.3% of 38,166 ultrasounds were among women with heterogeneously or extremely dense breasts, compared with 41.8% of 825,360 screening mammograms without supplemental screening (p <.0001). Among women with dense breasts, high interval invasive breast cancer risk was prevalent in 23.7% of screening ultrasounds compared with 18.5% of screening mammograms without supplemental imaging (adjusted odds ratio, 1.35; 95% CI, 1.30–1.39); intermediate/high advanced cancer risk was prevalent in 32.0% of screening ultrasounds versus 30.5% of screening mammograms without supplemental screening (adjusted odds ratio, 0.91; 95% CI, 0.89–0.94). Conclusions: Ultrasound screening was highly targeted to women with dense breasts, but only a modest proportion were at high mammography screening failure risk. A clinically significant proportion of women undergoing mammography screening alone were at high mammography screening failure risk. Whole‐breast ultrasound screening is highly targeted to women with dense breasts, but only a modest proportion are at high risk of interval or advanced breast cancer. Consideration of other breast cancer risk factors beyond breast density could facilitate identification of women at high risk of mammography screening failures who may be appropriate for supplemental ultrasound screening. [ABSTRACT FROM AUTHOR]

Objective: To determine whether invasive lobular carcinoma (ILC) extent is more accurately depicted with preoperative MRI (pMRI) than conventional imaging (mammography and/or ultrasound). Methods: After IRB approval, we retrospectively identified women with pMRIs (February 2005 to January 2014) to evaluate pure ILC excluding those with ipsilateral pMRI BI-RADS 4 or 5 findings or who had neoadjuvant chemotherapy. Agreement between imaging and pathology sizes was summarized using Bland-Altman plots, absolute and percent differences, and the intraclass correlation coefficient (ICC). Rates of underestimation and overestimation were evaluated and their associations with clinical features were explored. Results: Among the 56 women included, pMRI demonstrated better agreement with pathology than conventional imaging by mean absolute difference (1.6 mm versus -7.8 mm, P < 0.001), percent difference (10.3% versus -16.4%, P < 0.001), and ICC (0.88 versus 0.61, P = 0.019). Conventional imaging more frequently underestimated ILC span than pMRI using a 5 mm difference threshold (24/56 (43%) versus 10/56 (18%), P < 0.001), a 25% threshold (19/53 (36%) versus 10/53 (19%), P = 0.035), and T category change (17/56 (30%) versus 7/56 (13%), P = 0.006). Imaging-pathology size concordance was greater for MRI-described solitary masses than other lesions for both MRI and conventional imaging (P < 0.05). Variability of conventional imaging was lower for patients ≥ the median age of 62 years than for younger patients (SD: 12 mm versus 22 mm, P = 0.012). Conclusion: MRI depicts pure ILC size more accurately than conventional imaging and may have particular value for younger women. [ABSTRACT FROM AUTHOR]

Background: National patterns of breast imaging in women with a personal history of breast cancer (PHBC) are unknown making evaluation of annual surveillance recommendations a challenge.Objective: To describe variation in use of mammography and breast magnetic resonance imaging (MRI) examinations beginning 6 months after diagnosis among women with PHBC in US community practice. We report on the breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type.Design: Longitudinal study using cross-sectional data.Setting: Breast Cancer Surveillance Consortium breast imaging facilities.Participants: 19,955 women diagnosed between 2005 and 2012 with AJCC stage 0-III incident breast cancer who had 69,386 mammograms and 3,553 breast MRI examinations from January 2005 to September 2013; median follow-up of 37.6 months (interquartile range, 22.1-60.7).Main Measures: Breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type.Key Results: Among women with a PHBC who received breast imaging, 89.4% underwent mammography alone, 0.8% MRI alone, and 10.3% had both mammography and MRI. About half of mammograms and MRIs were indicated for surveillance vs. diagnostic, with an increase in the proportion of surveillance exams as time from diagnosis increased (mammograms, 45.7% at 1 year to 72.2% after 5 years; MRIs, 54.8% at 1 year to 78.6% after 5 years). In the first post-diagnosis period, 32.8% of women had > 2 breast imaging examinations and of these, 65.8% were less than 6 months apart. During the first 5-year post-diagnosis, the frequency of examinations per year decreased and the interval between examinations shifted towards annual examinations.Conclusion: In women with a PHBC who received post-diagnosis imaging, a third underwent multiple breast imaging examinations per year during the first 2-year post-diagnosis despite recommendations for annual exams. As time since diagnosis increases, imaging indication shifts from diagnostic to surveillance. [ABSTRACT FROM AUTHOR]