Publications by authors named "Anne Marie McCarthy"

43 Publications

Imaging Surveillance of Breast Cancer Survivors with Digital Mammography versus Digital Breast Tomosynthesis.

Radiology 2021 02 22;298(2):308-316. Epub 2020 Dec 22.

From the Departments of Radiology (M.B., S.M., C.D.L.) and Medicine (A.M.M.), Massachusetts General Hospital, 55 Fruit St, WAC 240; Boston, MA 02114.

Background Among breast cancer survivors, detecting a breast cancer when it is asymptomatic (rather than symptomatic) improves survival; thus, imaging surveillance in these patients is warranted. Digital breast tomosynthesis (DBT) is used for screening, but data on DBT for surveillance in this high-risk population are limited. Purpose To determine whether DBT leads to improved screening performance metrics when compared with two-dimensional digital mammography among breast cancer survivors. Materials and Methods In this study, screening mammograms obtained in breast cancer survivors before and after DBT implementation were retrospectively reviewed (March 2008-February 2011 for the digital mammography group; January 2013-December 2017 for the DBT group). Mammograms were interpreted by breast imaging radiologists with the assistance of computer-aided detection. Performance metrics and tumor characteristics between the groups were compared using multivariable logistic regression models. Results The digital mammography and DBT groups were composed of 9019 and 22 887 mammographic examinations, respectively, in 8170 women (mean age, 62 years ± 12 [standard deviation]). In the DBT group, the abnormal interpretation rate was lower (5.8% [1331 of 22 887 examinations] vs 6.2% [563 of 9019 examinations]; odds ratio [OR], 0.80; 95% CI: 0.71, 0.91; = .001) and specificity was higher (95.0% [21 502 of 22 644 examinations] vs 94.7% [8424 of 8891 examinations]; OR, 1.23; 95% CI: 1.07, 1.41; = .003) than in the digital mammography group. The cancer detection rates did not differ (8.3 per 1000 examinations with DBT vs 10.6 with digital mammography; OR, 0.76; 95% CI: 0.57, 1.02; = .07). The proportions of screening-detected invasive cancers, versus in situ cancers, were similar (74% [140 of 189 cancers] in the DBT group vs 72% [69 of 96 cancers] in the digital mammography group; = .69). Of 86 interval cancers, 58% (50 of 86 cancers) manifested with symptoms, and 33% (28 of 86 cancers) were detected at screening MRI. Conclusion Among breast cancer survivors, screening with digital breast tomosynthesis led to fewer false-positive results and higher specificity but did not affect cancer detection. © RSNA, 2020 See also the editorial by Hooley and Butler in this issue.
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http://dx.doi.org/10.1148/radiol.2020201854DOI Listing
February 2021

Genetic Testing May Help Reduce Breast Cancer Disparities for African American Women.

J Natl Cancer Inst 2020 12;112(12):1179-1180

Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1093/jnci/djaa042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735768PMC
December 2020

Different associations of tumor PIK3CA mutations and clinical outcomes according to aspirin use among women with metastatic hormone receptor positive breast cancer.

BMC Cancer 2020 Apr 23;20(1):347. Epub 2020 Apr 23.

Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Introduction: The relationships among PIK3CA mutations, medication use and tumor progression remains poorly understood. Aspirin use post-diagnosis may modify components of the PI3K pathway, including AKT and mTOR, and has been associated with lower risk of breast cancer recurrence and mortality. We assessed time to metastasis (TTM) and survival with respect to aspirin use and tumor PIK3CA mutations among women with metastatic breast cancer.

Methods: Patients with hormone receptor positive, HER2 negative (HR+/HER2-) metastatic breast cancer treated in 2009-2016 who received tumor genotyping were included. Aspirin use between primary and metastatic diagnosis was extracted from electronic medical records. TTM and survival were estimated using Cox proportional hazards regression.

Results: Among 267 women with metastatic breast cancer, women with PIK3CA mutated tumors had longer TTM than women with PIK3CA wildtype tumors (7.1 vs. 4.7 years, p = 0.008). There was a significant interaction between PIK3CA mutations and aspirin use on TTM (p = 0.006) and survival (p = 0.026). PIK3CA mutations were associated with longer TTM among aspirin non-users (HR = 0.60 95% CI:0.44-0.82 p = 0.001) but not among aspirin users (HR = 1.57 0.86-2.84 p = 0.139). Similarly, PIK3CA mutations were associated with reduced mortality among aspirin non-users (HR = 0.70 95% CI:0.48-1.02 p = 0.066) but not among aspirin users (HR = 1.75 95% CI:0.88-3.49 p = 0.110).

Conclusions: Among women who develop metastatic breast cancer, tumor PIK3CA mutations are associated with slower time to progression and mortality only among aspirin non-users. Larger studies are needed to confirm this finding and examine the relationship among aspirin use, tumor mutation profile, and the overall risk of breast cancer progression.
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http://dx.doi.org/10.1186/s12885-020-06810-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181475PMC
April 2020

Breast Cancer Screening with Digital Breast Tomosynthesis: Are Initial Benefits Sustained?

Radiology 2020 06 7;295(3):529-539. Epub 2020 Apr 7.

From the Department of Radiology (M.B., P.A.D., K.P.L., C.D.L.), Institute for Technology Assessment (S.M.), and Department of Medicine (A.M.M.), Massachusetts General Hospital, 55 Fruit St, WAC 240, Boston, MA 02114.

Background Performance metrics with digital breast tomosynthesis (DBT) are based on early experiences. There is limited research on whether the benefits of DBT are sustained. Purpose To determine whether improved screening performance metrics with DBT are sustained over time at the population level and after the first screening round at the individual level. Materials and Methods A retrospective review was conducted of screening mammograms that had been obtained before DBT implementation (March 2008 to February 2011, two-dimensional digital mammography [DM] group) and for 5 years after implementation (January 2013 to December 2017, DBT1-DBT5 groups, respectively). Patients who underwent DBT were also categorized according to the number of previous DBT examinations they had undergone. Performance metrics were compared between DM and DBT groups and between patients with no previous DBT examinations and those with at least one prior DBT examination by using multivariable logistic regression models. Results The DM group consisted of 99 582 DM examinations in 55 086 women (mean age, 57.3 years ± 11.6 [standard deviation]). The DBT group consisted of 205 048 examinations in 76 276 women (mean age, 58.2 years ± 11.2). There were no differences in the cancer detection rate (CDR) between DM and DBT groups (4.6-5.8 per 1000 examinations, = .08 to = .95). The highest CDR was observed with a woman's first DBT examination (6.1 per 1000 examinations vs 4.4-5.7 per 1000 examinations with at least one prior DBT examination, = .001 to = .054). Compared with the DM group, the DBT1 group had a lower abnormal interpretation rate (AIR) (adjusted odds ratio [AOR], 0.85; < .001), which remained reduced in the DBT2, DBT3, and DBT5 groups ( < .001 to = .02). The reduction in AIR was also sustained after the first examination ( < .001 to = .002). Compared with the DM group, the DBT1 group had a higher specificity (AOR, 1.20; < .001), which remained increased in DBT2, DBT3, and DBT5 groups ( < .001 to = .004). The increase in specificity was also sustained after the first examination ( < .001 to = .01). Conclusion The benefits of reduced false-positive examinations and higher specificity with screening tomosynthesis were sustained after the first screening round at the individual level. © RSNA, 2020 See also the editorial by Taourel in this issue.
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http://dx.doi.org/10.1148/radiol.2020191030DOI Listing
June 2020

Performance of Breast Cancer Risk-Assessment Models in a Large Mammography Cohort.

J Natl Cancer Inst 2020 05;112(5):489-497

Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA.

Background: Several breast cancer risk-assessment models exist. Few studies have evaluated predictive accuracy of multiple models in large screening populations.

Methods: We evaluated the performance of the BRCAPRO, Gail, Claus, Breast Cancer Surveillance Consortium (BCSC), and Tyrer-Cuzick models in predicting risk of breast cancer over 6 years among 35 921 women aged 40-84 years who underwent mammography screening at Newton-Wellesley Hospital from 2007 to 2009. We assessed model discrimination using the area under the receiver operating characteristic curve (AUC) and assessed calibration by comparing the ratio of observed-to-expected (O/E) cases. We calculated the square root of the Brier score and positive and negative predictive values of each model.

Results: Our results confirmed the good calibration and comparable moderate discrimination of the BRCAPRO, Gail, Tyrer-Cuzick, and BCSC models. The Gail model had slightly better O/E ratio and AUC (O/E = 0.98, 95% confidence interval [CI] = 0.91 to 1.06, AUC = 0.64, 95% CI = 0.61 to 0.65) compared with BRCAPRO (O/E = 0.94, 95% CI = 0.88 to 1.02, AUC = 0.61, 95% CI = 0.59 to 0.63) and Tyrer-Cuzick (version 8, O/E = 0.84, 95% CI = 0.79 to 0.91, AUC = 0.62, 95% 0.60 to 0.64) in the full study population, and the BCSC model had the highest AUC among women with available breast density information (O/E = 0.97, 95% CI = 0.89 to 1.05, AUC = 0.64, 95% CI = 0.62 to 0.66). All models had poorer predictive accuracy for human epidermal growth factor receptor 2 positive and triple-negative breast cancers than hormone receptor positive human epidermal growth factor receptor 2 negative breast cancers.

Conclusions: In a large cohort of patients undergoing mammography screening, existing risk prediction models had similar, moderate predictive accuracy and good calibration overall. Models that incorporate additional genetic and nongenetic risk factors and estimate risk of tumor subtypes may further improve breast cancer risk prediction.
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http://dx.doi.org/10.1093/jnci/djz177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225681PMC
May 2020

Long-Term Impact of a Culturally Tailored Patient Navigation Program on Disparities in Breast Cancer Screening in Refugee Women After the Program's End.

Health Equity 2019 14;3(1):205-210. Epub 2019 May 14.

Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.

To examine the long-term effects of a patient navigation (PN) program for mammography screening tailored to refugee women and to assess screening utilization among these women after PN ended. We assessed the proportion of patients completing mammography screening during the prior 2 years during 2012-2016 for refugee women who had previously received PN compared with that of English-speaking women cared for at the same health center during the same period, both overall and stratifying by age. We used logistic regression to compare screening completion between refugees and English speakers, adjusting for age, race, insurance status, number of clinic visits, and clustering by primary care physician and to test trends in screening over time. In 2012, the year when the funding for PN ceased, among 126 refugee women eligible for breast cancer screening, mammography screening rates were significantly higher among refugees (90.5%, 95% confidence interval [CI]: 83.5-94.7%) than among English speakers (81.9%, 95% CI: 76.2-86.5%, =0.006). By 2016, screening rates decreased among refugee women (76.5%, 95% CI: 61.6-86.9%, =0.023) but were not statistically significantly different from those among English-speaking women (80.5%, 95% CI: 74.4-85.3%, =0.460). Screening prevalence for refugee women remained above the pre-PN program screening levels, and considerably so in women <50 years. The culturally and language-tailored PN program for refugee women appeared to have persistent effects, with refugee women maintaining similar levels of mammography screening to English-speaking patients 5 years after the PN program's end.
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http://dx.doi.org/10.1089/heq.2018.0104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524343PMC
May 2019

Digital 2D versus Tomosynthesis Screening Mammography among Women Aged 65 and Older in the United States.

Radiology 2019 06 2;291(3):582-590. Epub 2019 Apr 2.

From the Department of Radiology (M.B., N.P., C.D.L.), Institute for Technology Assessment (S.M.), and Department of Medicine (A.M.M.), Massachusetts General Hospital, 55 Fruit St, WAC 240, Boston, MA 02114.

Background Although breast cancer incidence and mortality rates increase with advancing age, there are limited data on the benefits and risks of screening mammography in older women and on the performance of two-dimensional digital mammography (DM) and digital breast tomosynthesis (DBT) in older women. Purpose To compare performance metrics of DM and DBT among women aged 65 years and older. Materials and Methods For this retrospective study, consecutive screening mammograms in patients aged 65 years and older from March 2008 to February 2011 (DM group) and from January 2013 to December 2015 (DBT group) were reviewed. Cancer detection rate, abnormal interpretation rate, positive predictive values, sensitivity, and specificity were calculated. Multivariable logistic regression models were fit to compare performance metrics in the DM versus DBT groups. Results The DM group had 15 019 women (mean age ± standard deviation, 72.7 years ± 6.3), and the DBT group had 20 646 women (mean age, 72.1 years ± 5.9). After adjusting for multiple variables, there was no difference in cancer detection rate between the DM and DBT groups (6.9 vs 8.2 per 1000 examinations; adjusted odds ratio [AOR], 1.13; = .23). Compared with the DM group, the DBT group had a lower abnormal interpretation rate (5.7% vs 5.8%; AOR, 0.88; < .001), higher positive predictive value 1 (14.5% vs 11.9%; AOR, 1.26; = .03), and higher specificity (95.1% vs 94.8%; AOR, 1.18; < .001). The DBT group had a higher proportion of invasive cancers relative to in situ cancers (81.1% vs 74.4%; = .06) and fewer node-positive cancers (10.2% vs 16.6%; = .054) than did the DM group. Conclusion In women aged 65 years and older, integration of digital breast tomosynthesis led to improved performance metrics, with a lower abnormal interpretation rate, higher positive predictive value 1, and higher specificity. © RSNA, 2019 See also the editorial by Philpotts and Durand in this issue.
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http://dx.doi.org/10.1148/radiol.2019181637DOI Listing
June 2019

Effect of Mammographic Screening Modality on Breast Density Assessment: Digital Mammography versus Digital Breast Tomosynthesis.

Radiology 2019 05 19;291(2):320-327. Epub 2019 Mar 19.

From the Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 3710 Hamilton Walk, Room G601E Goddard Building, Philadelphia, PA 19104 (A.G., L.P., M.S., D.K., E.F.C.); and Department of Medicine, Massachusetts General Hospital, Boston, Mass (A.M.M.).

Background Breast Imaging Reporting and Data System (BI-RADS) breast density categories assigned by interpreting radiologists often influence decisions surrounding supplemental breast cancer screening and risk assessment. The landscape of mammographic screening continuously evolves, and different mammographic screening modalities may result in different perception of density, reflected in different assignment of BI-RADS density categories. Purpose To investigate the effect of screening mammography modality on BI-RADS breast density assessments. Materials and Methods Data were retrospectively analyzed from 24 736 individual women (42.3% [10 455 of 24 736] white women, 57.7% [14 281 of 24 736] black women; mean age, 56.3 years; age range, 40.0-74.9 years) who underwent from one to seven mammographic screening examinations from September 2010 through February 2017 (60 766 examinations). Three screening modalities were used: digital mammography alone (8935 examinations); digital mammography with digital breast tomosynthesis (DBT; 30 779 examinations); and synthetic mammography with DBT (21 052 examinations). Random-effects logistic regression analysis was performed to estimate the likelihood of assignment to high versus low BI-RADS density category according to each modality, adjusted for ethnicity, age, body mass index (BMI), and radiologist. The interactions of modality with ethnicity and BMI on density categorization were also tested with the model. Results Women screened with DBT versus digital mammography alone had lower likelihood regarding categorization of high density breasts (digital mammography and DBT vs digital mammography: odds ratio, 0.69 [95% confidence interval: 0.61, 0.80], < .001; synthetic mammography and DBT vs digital mammography: odds ratio, 0.43 [95% confidence interval: 0.37, 0.50], < .001). Lower likelihood of high density was also observed at synthetic mammography and DBT compared with digital mammography and DBT (odds ratio, 0.62; 95% confidence interval: 0.56, 0.69; < .001). There were interactions of modality with ethnicity ( = .007) and BMI ( = .003) on breast density assessment, with greater differences in density categorization according to modality observed for black women than for white women and groups with higher BMI. Conclusion Breast density categorization may vary by screening mammographic modality, and this effect appears to vary by ethnicity and body mass index. © RSNA, 2019 See also the editorial by Philpotts in this issue.
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http://dx.doi.org/10.1148/radiol.2019181740DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6493215PMC
May 2019

Persistent Underutilization of BRCA1/2 Testing Suggest the Need for New Approaches to Genetic Testing Delivery.

J Natl Cancer Inst 2019 08;111(8):751-753

See the Notes section for the full list of author's affiliations.

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http://dx.doi.org/10.1093/jnci/djz009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695316PMC
August 2019

Multilevel Predictors of Continued Adherence to Breast Cancer Screening Among Women Ages 50-74 Years in a Screening Population.

J Womens Health (Larchmt) 2019 08 27;28(8):1051-1059. Epub 2018 Nov 27.

13Cancer Research and Biostatistics, Seattle, Washington.

U.S. women of ages 50-74 years are recommended to receive screening mammography at least biennially. Our objective was to evaluate multilevel predictors of nonadherence among screened women, as these are not well known. A cohort study was conducted among women of ages 50-74 years with a screening mammogram in 2011 with a negative finding (Breast Imaging-Reporting and Data System 1 or 2) within Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium research centers. We evaluated the association between woman-level factors, radiology facility, and PROSPR research center, and nonadherence to breast cancer screening guidelines, defined as not receiving breast imaging within 27 months of an index screening mammogram. Multilevel mixed-effects logistic regression was used to calculate odds ratios and 95% confidence intervals. Nonadherence to guideline-recommended screening interval was 15.5% among 51,241 women with a screening mammogram. Non-Hispanic Asian/Pacific Islander women, women of other races, heavier women, and women of ages 50-59 years had a greater odds of nonadherence. There was no association with ZIP code median income. Nonadherence varied by research center and radiology facility (variance = 0.10, standard error = 0.03). Adjusted radiology facility nonadherence rates ranged from 10.0% to 26.5%. One research center evaluated radiology facility communication practices for screening reminders and scheduling, but these were not associated with nonadherence. Breast cancer screening interval nonadherence rates in screened women varied across radiology facilities even after adjustment for woman-level characteristics and research center. Future studies should investigate other characteristics of facilities, practices, and health systems to determine factors integral to increasing continued adherence to breast cancer screening.
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http://dx.doi.org/10.1089/jwh.2018.6997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703243PMC
August 2019

Comparison of performance metrics with digital 2D versus tomosynthesis mammography in the diagnostic setting.

Eur Radiol 2019 Feb 2;29(2):477-484. Epub 2018 Jul 2.

Division of Breast Imaging/Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, WAC 240, Boston, MA, USA.

Objectives: To compare performance metrics between digital 2D mammography (DM) and digital breast tomosynthesis (DBT) in the diagnostic setting.

Methods: Consecutive diagnostic examinations from August 2008 to February 2011 (DM group) and from January 2013 to July 2015 (DM/DBT group) were reviewed. Core biopsy and surgical pathology results within 365 days after the mammogram were collected. Performance metrics, including cancer detection rate (CDR), abnormal interpretation rate (AIR), positive predictive value (PPV) 2, PPV3, sensitivity, and specificity were calculated. Multivariable logistic regression models were fit to compare performance metrics in the DM and DM/DBT groups while adjusting for clinical covariates.

Results: A total of 22,883 mammograms were performed before DBT integration (DM group), and 22,824 mammograms were performed after complete DBT integration (DM/DBT group). After adjusting for multiple variables, the CDR was similar in both groups (38.2 per 1,000 examinations in the DM/DBT group versus 31.3 per 1,000 examinations in the DM group, p = 0.14); however, a higher proportion of cancers were invasive rather than in situ in the DM/DBT group [83.7% (731/873) versus 72.3% (518/716), p < 0.01]. The AIR was lower in the DM/DBT group (p < 0.01), and PPV2, PPV3, and specificity were higher in the DM/DBT group (all p = 0.01 or p < 0.01).

Conclusions: Complete integration of DBT into the diagnostic setting is associated with improved diagnostic performance. Increased utilization of DBT may thus result in better patient outcomes and lead to a shift in the benchmarks that have been established for DM.

Key Points: • Integration of tomosynthesis into the diagnostic setting is associated with improved performance. • A higher proportion of cancers are invasive rather than in situ with digital breast tomosynthesis. • Increased utilization of tomosynthesis may lead to a shift in established benchmarks.
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http://dx.doi.org/10.1007/s00330-018-5596-7DOI Listing
February 2019

Medical oncologists' willingness to participate in bundled payment programs.

BMC Health Serv Res 2018 05 31;18(1):391. Epub 2018 May 31.

Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 740, Boston, MA, 02114, USA.

Background: Bundled payment programs play an increasingly important role in transforming reimbursement for oncologic care. We assessed determinants of oncologists' willingness to participate in bundled payment programs for breast cancer. We hypothesized that providers would be more likely to participate in bundled payment programs if offered higher levels of reimbursement for each episode of care.

Methods: Oncologists from Florida, New Jersey, New York, and Pennsylvania were identified in the AMA database or by patients listed in state cancer registries. Providers were randomized to receive one of four versions of a survey describing bundled payment programs offering different levels of compensation for the first year of localized breast cancer treatment ($5000, $10,000, $15,000, or $20,000). Physicians rated their likelihood of participation in a bundled program on a Likert scale. Logistic regression was used to analyze determinants of likelihood of participation in bundling.

Results: Among 460 respondents, only 17% of oncologists were highly likely to participate in a bundled program paying $5000 for the first year of care, rising to 41% for the $15,000 program, but falling to 34% for the $20,000 program. Likelihood of participation was higher among oncologists who were male, older, and believed that cancer patients should not be offered high-cost drugs with minimal survival benefit.

Conclusion: Our results suggest that medical oncologists have limited enthusiasm for bundled payments, and higher payments may not overcome resistance to bundling among a substantial proportion of physicians.
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http://dx.doi.org/10.1186/s12913-018-3202-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984411PMC
May 2018

Uptake of BRCA 1/2 and oncotype DX testing by medical and surgical oncologists.

Breast Cancer Res Treat 2018 Aug 8;171(1):173-180. Epub 2018 May 8.

Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA,, 02114, USA.

Purpose: The diffusion of genomic testing is critical to the success of precision medicine, but there is limited information on oncologists' uptake of genetic technology. We aimed to assess the frequency with which medical oncologists and surgeons order BRCA 1/2 and Oncotype DX testing for breast cancer patients.

Methods: We surveyed 732 oncologists and surgeons treating breast cancer patients. Physicians were from Florida, New York, New Jersey, and Pennsylvania, and were listed in the 2010 AMA Masterfile or identified by patients.

Results: 80.6% of providers ordered BRCA 1/2 testing at least sometimes and 85.4% ordered Oncotype DX (p = 0.01). More frequent ordering of BRCA 1/2 was associated with more positive attitudes toward genetic innovation (OR 1.14, p = 0.001), a belief that testing was likely to be covered by patients' insurance (OR 2.84, p < 0.001), and more frequent ordering of Oncotype DX testing (OR 8.69, p < 0.001). More frequent use of Oncotype DX was associated with a belief that testing was likely to be covered by insurance (OR 7.33, p < 0.001), as well as with more frequent ordering of BRCA 1/2 testing (OR 9.48, p < 0.001).

Conclusions: Nearly one in five providers never or rarely ever ordered BRCA 1/2 testing for their breast cancer patients, and nearly 15% never or rarely ever ordered Oncotype DX. Less frequent ordering of BRCA 1/2 is associated with less frequent use of Oncotype DX testing, and vice versa. Those who do not order BRCA 1/2 testing report less positive attitudes toward genetic innovation. Further education of this subset of providers regarding the benefits of precision medicine may enable more rapid diffusion of genetic technology.
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http://dx.doi.org/10.1007/s10549-018-4810-2DOI Listing
August 2018

Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium.

CA Cancer J Clin 2018 05 30;68(3):199-216. Epub 2018 Mar 30.

Physician in Chief, General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA.

Timely follow-up for positive cancer screening results remains suboptimal, and the evidence base to inform decisions on optimizing the timeliness of diagnostic testing is unclear. This systematic review evaluated published studies regarding time to follow-up after a positive screening for breast, cervical, colorectal, and lung cancers. The quality of available evidence was very low or low across cancers, with potential attenuated or reversed associations from confounding by indication in most studies. Overall, evidence suggested that the risk for poorer cancer outcomes rises with longer wait times that vary within and across cancer types, which supports performing diagnostic testing as soon as feasible after the positive result, but evidence for specific time targets is limited. Within these limitations, we provide our opinion on cancer-specific recommendations for times to follow-up and how existing guidelines relate to the current evidence. Thresholds set should consider patient worry, potential for loss to follow-up with prolonged wait times, and available resources. Research is needed to better guide the timeliness of diagnostic follow-up, including considerations for patient preferences and existing barriers, while addressing methodological weaknesses. Research is also needed to identify effective interventions for reducing wait times for diagnostic testing, particularly in underserved or low-resource settings. CA Cancer J Clin 2018;68:199-216. © 2018 American Cancer Society.
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http://dx.doi.org/10.3322/caac.21452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5980732PMC
May 2018

Communication Practices of Mammography Facilities and Timely Follow-up of a Screening Mammogram with a BI-RADS 0 Assessment.

Acad Radiol 2018 09 9;25(9):1118-1127. Epub 2018 Feb 9.

University of Vermont and State Agricultural College, Vineyard Haven, Massachusetts.

Rationale And Objectives: The objective of this study was to evaluate the association of communication practices with timely follow-up of screening mammograms read as Breast Imaging Reporting and Data Systems (BI-RADS) 0 in the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

Materials And Methods: A radiology facility survey was conducted in 2015 with responses linked to screening mammograms obtained in 2011-2014. We considered timely follow-up to be within 15 days of the screening mammogram. Generalized estimating equation models were used to evaluate the association between modes of communication with patients and providers and timely follow-up, adjusting for PROSPR site, patient age, and race and ethnicity.

Results: The analysis included 34,680 mammography examinations with a BI-RADS 0 assessment among 28 facilities. Across facilities, 85.6% of examinations had a follow-up within 15 days. Patients in a facility where routine practice was to contact the patient by phone if follow-up imaging was recommended were more likely to have timely follow-up (odds ratio [OR] 4.63, 95% confidence interval [CI] 2.76-7.76), whereas standard use of mail was associated with reduced timely follow-up (OR 0.47, 95% CI 0.30-0.75). Facilities that had standard use of electronic medical records to report the need for follow-up imaging to a provider had less timely follow-up (OR 0.56, 95% CI 0.35-0.90). Facilities that routinely contacted patients by mail if they missed a follow-up imaging visit were more likely to have timely follow-up (OR 1.65, 95% CI 1.02-2.69).

Conclusions: Our findings support the value of telephone communication to patients in relation to timely follow-up. Future research is needed to evaluate the role of communication in completing the breast cancer screening episode.
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http://dx.doi.org/10.1016/j.acra.2017.12.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6402569PMC
September 2018

Breast Cancer Characteristics Associated with 2D Digital Mammography versus Digital Breast Tomosynthesis for Screening-detected and Interval Cancers.

Radiology 2018 Apr 22;287(1):49-57. Epub 2017 Dec 22.

From the Division of Breast Imaging, Department of Radiology (M.B., S.G., K.P.L., P.A.D., C.D.L.), and Department of Medicine (A.M.M.), Massachusetts General Hospital, 55 Fruit St, WAC 240, Boston, MA 02114.

Purpose To determine whether the rates and tumor characteristics of screening-detected and interval cancers differ for two-dimensional digital mammography (DM) versus digital breast tomosynthesis (DBT) mammography. Materials and Methods Consecutive screening mammograms from January 2009 to February 2011 (DM group, before DBT integration) and from January 2013 to February 2015 (DBT group, after complete DBT integration) were reviewed. Cancers were considered screening detected if diagnosed within 365 days of a positive screening examination and interval if diagnosed within 365 days of a negative screening examination. Z tests were used to compare cancers on DM versus DBT examinations. Results A total of 948 breast cancers were diagnosed after 78 385 DM and 76 896 DBT examinations. Although the overall rate of screening-detected cancers was similar with DM and DBT (5.0 vs 5.0 per 1000 examinations, P = .98), a higher proportion of screening-detected cancers were invasive rather than in situ with DBT (74.2% [287 of 387] vs 66.0% [260 of 394], P = .01). There were no significant differences in tumor characteristics, including size at pathologic examination, grade, hormone receptor status, and nodal status, between the screening-detected invasive cancers on DM versus DBT (P = .09-.99). The rate of interval cancers was similar with DM and DBT (1.1 vs 1.1 per 1000 examinations, P = .84). Compared with symptomatic interval cancers, magnetic resonance imaging-detected interval cancers were more likely to be minimal cancers. Conclusion The overall rates of screening-detected and interval cancers are similar with DM and DBT, but a higher proportion of screening-detected cancers are invasive rather than in situ with DBT. RSNA, 2017.
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http://dx.doi.org/10.1148/radiol.2017171148DOI Listing
April 2018

Healthcare System Distrust, Physician Trust, and Patient Discordance with Adjuvant Breast Cancer Treatment Recommendations.

Cancer Epidemiol Biomarkers Prev 2017 12 29;26(12):1745-1752. Epub 2017 Sep 29.

Massachusetts General Hospital, Boston, Massachusetts.

Adjuvant therapy after breast cancer surgery decreases recurrence and increases survival, yet not all women receive and complete it. Previous research has suggested that distrust in medical institutions plays a role in who initiates adjuvant treatment, but has not assessed treatment completion, nor the potential mediating role of physician distrust. Women listed in Pennsylvania and Florida cancer registries, who were under the age of 65 when diagnosed with localized invasive breast cancer between 2005 and 2007, were surveyed by mail in 2007 to 2009. Survey participants self-reported demographics, cancer stage and treatments, treatment discordance (as defined by not following their surgeon or oncologist treatment recommendation), healthcare system distrust, and physician trust. Age and cancer stage were verified against cancer registry records. Logistic regression assessed the relationship between highest and lowest tertiles of healthcare system distrust and the dichotomous outcome of treatment discordance, controlling for demographics and clinical treatment factors, and testing for mediation by physician trust. Of the 2,754 participants, 30.2% ( = 832) reported not pursing at least one recommended treatment. The mean age was 52. Patients in the highest tertile of healthcare system distrust were 22% more likely to report treatment discordance than the lowest tertile; physician trust did not mediate the association between healthcare system distrust and treatment discordance. Healthcare system distrust is positively associated with treatment discordance, defined as failure to initiate or complete physician-recommended adjuvant treatment after breast cancer. Interventions should test whether or not resolving institutional distrust reduces treatment discordance. .
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http://dx.doi.org/10.1158/1055-9965.EPI-17-0479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5712243PMC
December 2017

BI-RADS Category 3 Comparison: Probably Benign Category after Recall from Screening before and after Implementation of Digital Breast Tomosynthesis.

Radiology 2017 12 17;285(3):778-787. Epub 2017 Jul 17.

From the Department of Radiology, Breast Imaging Section, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-4283 (E.S.M., S.P.W., M.D.S., E.F.C.); and General Medicine Division, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (A.M.M.).

Purpose To evaluate Breast Imaging Reporting and Data System (BI-RADS) category 3 assessment at diagnostic examination after recall from screening in a large urban population after implementation of digital breast tomosynthesis (DBT) by focusing both on overall use and use stratified by recalled finding type and outcome at 2 years. Materials and Methods This was an intuitional review board-approved and HIPAA-compliant retrospective review of 10 728 digital mammography (DM) examinations from September 1, 2010, to August 30, 2011, and 15 571 screening DBT examinations from October 1, 2011, to February 28, 2013. The recall populations for DM and DBT were 1112 of 10 728 (10.4% of women screened) and 1366 of 15 571 (8.8% of women screened), respectively. Recall examinations were classified according to finding type: calcifications, asymmetry or focal asymmetry, mass, and architectural distortion. Differences between groups were compared by using the χ test. Results Although there was no significant change in the utilization rate of BI-RADS category 3 in those patients screened with DM compared with DBT (168 of 10 728, 1.6% for DM vs 206 of 15 571, 1.3% for DBT; P = .102), there was a mean overall reduction of 2.4 women per 1000 (95% confidence interval [CI]: -0.5, 5.4) recommended for short-term follow-up. Lesion types given a BI-RADS category 3 assessment after diagnostic work-up did not change. The distribution of recalled finding types significantly changed with DBT, with increased recall examinations for architectural distortion and mass (P < .001) and decreased recall examinations for asymmetries (P ≤ .001). There was no change in recall examinations for calcifications (P = .977). Conclusion Screening with DBT did not significantly change the utilization rate of BI-RADS category 3 classification; however, the overall number of patients recommended for short-interval follow-up decreased by a mean of 2.4 women per 1000 (95% CI: -0.5, 5.4). RSNA, 2017 Online supplemental material is available for this article.
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http://dx.doi.org/10.1148/radiol.2017162837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708302PMC
December 2017

Disparities in contralateral prophylactic mastectomy use among women with early-stage breast cancer.

NPJ Breast Cancer 2017 27;3. Epub 2017 Jan 27.

Massachusetts General Hospital, 50 Staniford Street, 9-940L, Boston, MA 02114 USA.

Contralateral prophylactic mastectomy use has increased over the past decades among women with early-stage breast cancer. Racial differences in contralateral prophylactic mastectomy use are well described, but with unclear causes. This study examined contralateral prophylactic mastectomy use among black and white women and the contribution of differences in perceived risk to differences in use. We surveyed women diagnosed with early-stage unilateral breast cancer between ages 41-64 in Pennsylvania and Florida between 2007-2009 to collect data on breast cancer treatment, family history, education, income, insurance, and perceived risk. Clinical factors-age,stage at diagnosis, receptor status-were obtained from cancer registries. The relationships between patient factors and contralateral prophylactic mastectomy were assessed using logistic regression. The interaction between race and contralateral prophylactic mastectomy on the perceived risk of second breast cancers was tested using linear regression. Of 2182 study participants, 18% of whites underwent contralateral prophylactic mastectomy compared with 10% of blacks ( < 0.001). The racial difference remained after adjustment for clinical factors and family history (odds ratio = 2.32, 95% confidence interval 1.76-3.06,  < 0.001). The association between contralateral prophylactic mastectomy and a reduction in the perceived risk of second breast cancers was significantly smaller for blacks than whites. Blacks were less likely than whites to undergo contralateral prophylactic mastectomy even after adjustment for clinical factors. This racial difference in use may relate to the smaller impact of contralateral prophylactic mastectomy on the perceived risk of second breast cancers among blacks than among whites. Future research is needed to understand the overall impact of perceived risk on decisions about contralateral prophylactic mastectomy and how that may explain racial differences in use.
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http://dx.doi.org/10.1038/s41523-017-0004-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5460130PMC
January 2017

Predictors of BRCA1/2 genetic testing among Black women with breast cancer: a population-based study.

Cancer Med 2017 Jul 19;6(7):1787-1798. Epub 2017 Jun 19.

Massachusetts General Hospital, Boston, Massachusetts.

Evidence shows that Black women diagnosed with breast cancer are substantially less likely to undergo BRCA testing and other multipanel genetic testing compared to White women, despite having a higher incidence of early-age onset breast cancer and triple-negative breast cancer (TNBC). Our study identifies predictors of BRCA testing among Black women treated for breast cancer and examines differences between BRCA testers and nontesters. We conducted an analysis of 945 Black women ages 18-64 diagnosed with localized or regional-stage invasive breast cancer in Pennsylvania and Florida between 2007 and 2009. Logistic regression was used to identify predictors of BRCA 1/2 testing. Few (27%) (n = 252) of the participants reported having BRCA testing. In the multivariate analysis, we found that perceived benefits of BRCA testing (predisposing factor) ([OR], 1.16; 95% CI: 1.11-1.21; P < 0.001), income (enabling factor) ([OR], 2.10; 95% CI: 1.16-3.80; p = 0.014), and BRCA mutation risk category (need factor) ([OR], 3.78; 95% CI: 2.31-6.19; P < 0.001) predicted BRCA testing. These results suggest that interventions to reduce disparities in BRCA testing should focus on identifying patients with high risk of mutation, increasing patient understanding of the benefits of BRCA testing, and removing financial and other administrative barriers to genetic testing.
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http://dx.doi.org/10.1002/cam4.1120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5504315PMC
July 2017

Breast cancer screening initiation after turning 40 years of age within the PROSPR consortium.

Breast Cancer Res Treat 2016 11 24;160(2):323-331. Epub 2016 Sep 24.

Cancer Research and Biostatistics, 1730 Minor Ave, Seattle, WA, 98101, USA.

Purpose: Although United States clinical guidelines differ, the earliest recommended age for average risk breast cancer screening is 40 years. Little is known about factors influencing screening initiation.

Methods: We conducted a cohort study within the National Cancer Institute-funded Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We identified 3413 women on their 40th birthday in primary care networks at Geisel School of Medicine at Dartmouth (DH) and Brigham and Women's Hospital (BWH) during 2011-2013 with no prior breast imaging or breast cancer. Cumulative incidence curves and Cox modeling were used to determine time from the 40th birthday to first breast cancer screening, cohort exit, or 42nd birthday. We calculated hazards ratios and 95 % confidence intervals from multivariable Cox proportional hazards models.

Results: Breast cancer screening cumulative incidence by the 42nd birthday was 62.9 % (BWH) and 39.8 % (DH). Factors associated with screening initiation were: a primary care visit within a year (HR 4.99, 95 % CI 4.23-5.89), an increasing number of primary care visits within a year (p for trend <0.0001), ZIP code of residence annual median household income ≤$52,000 (HR 0.79, 95 % CI 0.68-0.92), and health insurance type (Medicaid HR 0.72, 95 % CI 0.58-0.88; Medicare HR 0.55, 95 % CI 0.39-0.77; uninsured HR 0.37, 95 % CI 0.25-0.57).

Conclusions: Breast cancer screening uptake after the 40th birthday varies by health system, primary care visits, median household income, and health insurance type, suggesting the need for further exploration. Future research should evaluate screening performance metrics after initiation and consider cumulative benefits and risks associated with breast cancer screening over time.
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http://dx.doi.org/10.1007/s10549-016-3990-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576986PMC
November 2016

Health Care Segregation, Physician Recommendation, and Racial Disparities in BRCA1/2 Testing Among Women With Breast Cancer.

J Clin Oncol 2016 08 9;34(22):2610-8. Epub 2016 May 9.

Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Purpose: Racial disparities in BRCA1/2 testing have been documented, but causes of these disparities are poorly understood. The study objective was to investigate whether the distribution of black and white patients across cancer providers contributes to disparities in BRCA1/2 testing.

Patients And Methods: We conducted a population-based study of women in Pennsylvania and Florida who were 18 to 64 years old and diagnosed with invasive breast cancer between 2007 and 2009, linking cancer registry data, the American Medical Association Physician Masterfile, and patient and physician surveys. The study included 3,016 women (69% white, 31% black), 808 medical oncologists, and 732 surgeons.

Results: Black women were less likely to undergo BRCA1/2 testing than white women (odds ratio [OR], 0.40; 95% CI, 0.34 to 0.48; P < .001). This difference was attenuated but not eliminated by adjustment for mutation risk, clinical factors, sociodemographic characteristics, and attitudes about testing (OR, 0.66; 95% CI, 0.53 to 0.81; P < .001). The care of black and white women was highly segregated across surgeons and oncologists (index of dissimilarity 64.1 and 61.9, respectively), but adjusting for clustering within physician or physician characteristics did not change the size of the testing disparity. Black women were less likely to report that they had received physician recommendation for BRCA1/2 testing even after adjusting for mutation risk (OR, 0.66; 95% CI, 0.54 to 0.82; P < .001). Adjusting for physician recommendation further attenuated the testing disparity (OR, 0.76; 95% CI, 0.57 to 1.02; P = .06).

Conclusion: Although black and white patients with breast cancer tend to see different surgeons and oncologists, this distribution does not contribute to disparities in BRCA1/2 testing. Instead, residual racial differences in testing after accounting for patient and physician characteristics are largely attributable to differences in physician recommendations. Efforts to address these disparities should focus on ensuring equity in testing recommendations.
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http://dx.doi.org/10.1200/JCO.2015.66.0019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012689PMC
August 2016

Follow-Up of Abnormal Breast and Colorectal Cancer Screening by Race/Ethnicity.

Am J Prev Med 2016 10 28;51(4):507-12. Epub 2016 Apr 28.

Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Timely follow-up of abnormal tests is critical to the effectiveness of cancer screening, but may vary by screening test, healthcare system, and sociodemographic group.

Methods: Timely follow-up of abnormal mammogram and fecal occult blood testing or fecal immunochemical tests (FOBT/FIT) were compared by race/ethnicity using Population-Based Research Optimizing Screening through Personalized Regimens consortium data. Participants were women with an abnormal mammogram (aged 40-75 years) or FOBT/FIT (aged 50-75 years) in 2010-2012. Analyses were performed in 2015. Timely follow-up was defined as colonoscopy ≤3 months following positive FOBT/FIT; additional imaging or biopsy ≤3 months following Breast Imaging Reporting and Data System Category 0, 4, or 5 mammograms; or ≤9 months following Category 3 mammograms. Logistic regression was used to model receipt of timely follow-up adjusting for study site, age, year, insurance, and income.

Results: Among 166,602 mammograms, 10.7% were abnormal; among 566,781 FOBT/FITs, 4.3% were abnormal. Nearly 96% of patients with abnormal mammograms received timely follow-up versus 68% with abnormal FOBT/FIT. There was greater variability in receipt of follow-up across healthcare systems for positive FOBT/FIT than for abnormal mammograms. For mammography, black women were less likely than whites to receive timely follow-up (91.8% vs 96.0%, OR=0.71, 95% CI=0.51, 0.97). For FOBT/FIT, Hispanics were more likely than whites to receive timely follow-up than whites (70.0% vs 67.6%, OR=1.12, 95% CI=1.04, 1.21).

Conclusions: Timely follow-up among women was more likely for abnormal mammograms than FOBT/FITs, with small variations in follow-up rates by race/ethnicity and larger variation across healthcare systems.
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http://dx.doi.org/10.1016/j.amepre.2016.03.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5030116PMC
October 2016

Racial Differences in Quantitative Measures of Area and Volumetric Breast Density.

J Natl Cancer Inst 2016 10 29;108(10). Epub 2016 Apr 29.

Department of Medicine, Massachusetts General Hospital, Boston, MA (AMM, KA); Department of Radiology, University of Pennsylvania, Philadelphia, PA (BMK, LMP, MKH, MS, EFC, DK).

Background: Increased breast density is a strong risk factor for breast cancer and also decreases the sensitivity of mammographic screening. The purpose of our study was to compare breast density for black and white women using quantitative measures.

Methods: Breast density was assessed among 5282 black and 4216 white women screened using digital mammography. Breast Imaging-Reporting and Data System (BI-RADS) density was obtained from radiologists' reports. Quantitative measures for dense area, area percent density (PD), dense volume, and volume percent density were estimated using validated, automated software. Breast density was categorized as dense or nondense based on BI-RADS categories or based on values above and below the median for quantitative measures. Logistic regression was used to estimate the odds of having dense breasts by race, adjusted for age, body mass index (BMI), age at menarche, menopause status, family history of breast or ovarian cancer, parity and age at first birth, and current hormone replacement therapy (HRT) use. All statistical tests were two-sided.

Results: There was a statistically significant interaction of race and BMI on breast density. After accounting for age, BMI, and breast cancer risk factors, black women had statistically significantly greater odds of high breast density across all quantitative measures (eg, PD nonobese odds ratio [OR] = 1.18, 95% confidence interval [CI] = 1.02 to 1.37, P = .03, PD obese OR = 1.26, 95% CI = 1.04 to 1.53, P = .02). There was no statistically significant difference in BI-RADS density by race.

Conclusions: After accounting for age, BMI, and other risk factors, black women had higher breast density than white women across all quantitative measures previously associated with breast cancer risk. These results may have implications for risk assessment and screening.
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http://dx.doi.org/10.1093/jnci/djw104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5939658PMC
October 2016

Breast cancer screening using tomosynthesis in combination with digital mammography compared to digital mammography alone: a cohort study within the PROSPR consortium.

Breast Cancer Res Treat 2016 Feb 1;156(1):109-16. Epub 2016 Mar 1.

Cancer Research and Biostatistics, Seattle, WA, USA.

Digital breast tomosynthesis (DBT) is emerging as the new standard of care for breast cancer screening based on improved cancer detection coupled with reductions in recall compared to screening with digital mammography (DM) alone. However, many prior studies lack follow-up data to assess false negatives examinations. The purpose of this study is to assess if DBT is associated with improved screening outcomes based on follow-up data from tumor registries or pathology. Retrospective analysis of prospective cohort data from three research centers performing DBT screening in the PROSPR consortium from 2011 to 2014 was performed. Recall and biopsy rates were assessed from 198,881 women age 40-74 years undergoing screening (142,883 DM and 55,998 DBT examinations). Cancer, cancer detection, and false negative rates and positive predictive values were assessed on examinations with one year of follow-up. Logistic regression was used to compare DBT to DM adjusting for research center, age, prior breast imaging, and breast density. There was a reduction in recall with DBT compared to DM (8.7 vs. 10.4 %, p < 0.0001), with adjusted OR = 0.68 (95 % CI = 0.65-0.71). DBT demonstrated a statistically significant increase in cancer detection over DM (5.9 vs. 4.4/1000 screened, adjusted OR = 1.45, 95 % CI = 1.12-1.88), an improvement in PPV1 (6.4 % for DBT vs. 4.1 % for DM, adjusted OR = 2.02, 95 % CI = 1.54-2.65), and no significant difference in false negative rates for DBT compared to DM (0.46 vs. 0.60/1000 screened, p = 0.347). Our data support implementation of DBT screening based on increased cancer detection, reduced recall, and no difference in false negative screening examinations.
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http://dx.doi.org/10.1007/s10549-016-3695-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5536249PMC
February 2016

Variation in Screening Abnormality Rates and Follow-Up of Breast, Cervical and Colorectal Cancer Screening within the PROSPR Consortium.

J Gen Intern Med 2016 Apr;31(4):372-9

University of Vermont, Burlington, VT, USA.

Background: Primary care providers and health systems have prominent roles in guiding effective cancer screening.

Objective: To characterize variation in screening abnormality rates and timely initial follow-up for common cancer screening tests.

Design: Population-based cohort undergoing screening in 2011, 2012, or 2013 at seven research centers comprising the National Cancer Institute-sponsored Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

Participants: Adults undergoing mammography with or without digital breast tomosynthesis (n = 97,683 ages 40-75 years), fecal occult blood or fecal immunochemical tests (n = 759,553 ages 50-75 years), or Papanicolaou with or without human papillomavirus tests (n = 167,330 ages 21-65 years).

Intervention: Breast, colorectal, or cervical cancer screening.

Main Measures: Abnormality rates per 1000 screens; percentage with timely initial follow-up (within 90 days, except 9-month window for BI-RADS 3). Primary care clinic-level variation in percentage with screening abnormality and percentage with timely initial follow-up.

Key Results: There were 10,248/97,683 (104.9 per 1000) abnormal breast cancer screens, 35,847/759,553 (47.2 per 1000) FOBT/FIT-positive colorectal cancer screens, and 13,266/167,330 (79.3 per 1000) abnormal cervical cancer screens. The percentage with timely follow-up was 93.2 to 96.7 % for breast centers, 46.8 to 68.7  % for colorectal centers, and 46.6 % for the cervical cancer screening center (low-grade squamous intraepithelial lesions or higher). The primary care clinic variation (25th to 75th percentile) was smaller for the percentage with an abnormal screen (breast, 8.5-10.3 %; colorectal, 3.0-4.8 %; cervical, 6.3-9.9 %) than for the percentage with follow-up within 90 days (breast, 90.2-95.8 %; colorectal, 43.4-52.0 %; cervical, 29.6-61.4 %).

Conclusions: Variation in both the rate of screening abnormalities and their initial follow-up was evident across organ sites and primary care clinics. This highlights an opportunity for improving the delivery of cancer screening through focused study of patient, provider, clinic, and health system characteristics associated with timely follow-up of screening abnormalities.
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http://dx.doi.org/10.1007/s11606-015-3552-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4803707PMC
April 2016

Baseline Screening Mammography: Performance of Full-Field Digital Mammography Versus Digital Breast Tomosynthesis.

AJR Am J Roentgenol 2015 Nov;205(5):1143-8

1 Breast Imaging Division, Department of Radiology, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-4283.

Objective: Baseline mammography studies have significantly higher recall rates than mammography studies with available comparison examinations. Digital breast tomosynthesis reduces recalls when compared with digital mammographic screening alone, but many sites operate in a hybrid environment. To maximize the effect of screening digital breast tomosynthesis with limited resources, choosing which patient populations will benefit most is critical. This study evaluates digital breast tomosynthesis in the baseline screening population.

Materials And Methods: Outcomes were compared for 10,728 women who underwent digital mammography screening, including 1204 (11.2%) baseline studies, and 15,571 women who underwent digital breast tomosynthesis screening, including 1859 (11.9%) baseline studies. Recall rates, cancer detection rates, and positive predictive values were calculated. Logistic regression estimated the odds ratios of recall for digital mammography versus digital breast tomosynthesis for patients undergoing baseline screening and previously screened patients, adjusted for age, race, and breast density.

Results: In the baseline subgroup, recall rates for digital mammography and digital breast tomosynthesis screening were 20.5% and 16.0%, respectively (p = 0.002); digital breast tomosynthesis screening in the baseline subgroup resulted in a 22% reduction in recall compared with digital mammography, or 45 fewer patients recalled per 1000 patients screened. Digital breast tomosynthesis screening in the previously screened patients resulted in recall reduction of 14.3% (p < 0.001; p for interaction = 0.21). The recall rate reduction for baseline screening was especially pronounced in women younger than 50 years (p = 0.005). DBT implementation resulted in an increase in cancer detection in the baseline subgroup of 40.5% versus an increase in the previously screened subgroup of 17.4%. DBT implementation resulted in an increase in PPV1 in the baseline subgroup of 85% versus 35.3% in the previously screened subgroup, although the p-interaction was not significant.

Conclusion: If resources are limited, women younger than 50 years who are undergoing baseline screening or do not have prior available mammograms may benefit more from digital breast tomosynthesis than from digital mammography alone.
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http://dx.doi.org/10.2214/AJR.15.14406DOI Listing
November 2015

Racial differences in false-positive mammogram rates: results from the ACRIN Digital Mammographic Imaging Screening Trial (DMIST).

Med Care 2015 Aug;53(8):673-8

*Massachusetts General Hospital Department of Medicine and Harvard Medical School, Boston, MA †Department of Medicine ‡Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Background: Mammography screening reduces breast cancer mortality, but false-positive tests are common. Few studies have assessed racial differences in false-positive rates.

Objectives: We compared false-positive mammography rates for black and white women, and the effect of patient and facility characteristics on false positives.

Research Design And Subjects: A prospective cohort study. From a sample of the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), we identified black/African American (N=3176) or white (N=26,446) women with no prior breast surgery or breast cancer.

Measures: Race, demographics, and breast cancer risk factors were self-reported. Results of initial digital and film mammograms were assessed. False positives were defined as a positive mammogram (Breast Imaging Reporting and Data System category 0, 4, 5) with no cancer diagnosis within 15 months.

Results: The false-positive rate for digital mammograms was 9.2% for black women compared with 7.8% for white women (P=0.009). After adjusting for age, black women had 17% increased odds of false-positive digital mammogram compared with whites (OR=1.17; 95% CI, 1.01-1.35; P=0.033). This association was attenuated after adjusting for patient factors, prior films, and study site (OR=1.04; 95% CI, 0.91-1.20; P=0.561). There was no difference in the occurrence of false positives by race for film mammography.

Conclusions: Black women had higher frequency of false-positive digital mammograms explained by lack of prior films and study site.The variation in the disparity between the established technique (film) and the new technology (digital) raises the possibility that racial differences in screening quality may be greatest for new technologies.
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http://dx.doi.org/10.1097/MLR.0000000000000393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4503517PMC
August 2015

Increasing disparities in breast cancer mortality from 1979 to 2010 for US black women aged 20 to 49 years.

Am J Public Health 2015 Jul 23;105 Suppl 3:S446-8. Epub 2015 Apr 23.

Anne Marie McCarthy and Katrina Armstrong are with Massachusetts General Hospital and Harvard Medical School, Boston. Jianing Yang is with University of Pennsylvania, Philadelphia.

Racial disparities in breast cancer mortality persist, and young Black women have higher disease incidence compared with White women. We compared trends in breast cancer mortality for young Black and White women with mortality trends for other common diseases from 1979 to 2010. In contrast to other cancers, ischemic heart disease, and stroke, the breast cancer mortality disparity has widened over the past 30 years, suggesting that unique aspects of disease biology, prevention, and treatment may explain persistent racial differences for young women.
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http://dx.doi.org/10.2105/AJPH.2014.302297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455497PMC
July 2015