Publications by authors named "Janie M Lee"

73 Publications

Receipt of Screening Mammography by Insured Women Diagnosed With Breast Cancer and Impact on Outcomes.

J Natl Compr Canc Netw 2021 07 30. Epub 2021 Jul 30.

Department of Radiology, University of Washington School of Medicine; and.

Background: The purpose of this study was to determine factors associated with receipt of screening mammography by insured women before breast cancer diagnosis, and subsequent outcomes.

Patients And Methods: Using claims data from commercial and federal payers linked to a regional SEER registry, we identified women diagnosed with breast cancer from 2007 to 2017 and determined receipt of screening mammography within 1 year before diagnosis. We obtained patient and tumor characteristics from the SEER registry and assigned each woman a socioeconomic deprivation score based on residential address. Multivariable logistic regression models were used to evaluate associations of patient and tumor characteristics with late-stage disease and nonreceipt of mammography. We used multivariable Cox proportional hazards models to identify predictors of subsequent mortality.

Results: Among 7,047 women, 69% (n=4,853) received screening mammography before breast cancer diagnosis. Compared with women who received mammography, those with no mammography had a higher proportion of late-stage disease (34% vs 10%) and higher 5-year mortality (18% vs 6%). In multivariable modeling, late-stage disease was most associated with nonreceipt of mammography (odds ratio [OR], 4.35; 95% CI, 3.80-4.98). The Cox model indicated that nonreceipt of mammography predicted increased risk of mortality (hazard ratio [HR], 2.00; 95% CI, 1.64-2.43), independent of late-stage disease at diagnosis (HR, 5.00; 95% CI, 4.10-6.10), Charlson comorbidity index score ≥1 (HR, 2.75; 95% CI, 2.26-3.34), and negative estrogen receptor/progesterone receptor status (HR, 2.09; 95% CI, 1.67-2.61). Nonreceipt of mammography was associated with younger age (40-49 vs 50-59 years; OR, 1.69; 95% CI, 1.45-1.96) and increased socioeconomic deprivation (OR, 1.05 per decile increase; 95% CI, 1.03-1.07).

Conclusions: In a cohort of insured women diagnosed with breast cancer, nonreceipt of screening mammography was significantly associated with late-stage disease and mortality, suggesting that interventions to further increase uptake of screening mammography may improve breast cancer outcomes.
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http://dx.doi.org/10.6004/jnccn.2020.7801DOI Listing
July 2021

Prioritizing breast imaging services during the COVID pandemic: A survey of breast imaging facilities within the Breast Cancer Surveillance Consortium.

Prev Med 2021 10 30;151:106540. Epub 2021 Jun 30.

Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA; Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Davis, CA, USA.

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.
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http://dx.doi.org/10.1016/j.ypmed.2021.106540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241650PMC
October 2021

Accuracy of Preoperative Breast MRI Versus Conventional Imaging in Measuring Pathologic Extent of Invasive Lobular Carcinoma.

J Breast Imaging 2021 May-Jun;3(3):288-298. Epub 2021 Apr 29.

University of Washington School of Medicine, Department of Radiology, Seattle, WA, USA.

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, < 0.001), percent difference (10.3% versus -16.4%, < 0.001), and ICC (0.88 versus 0.61, = 0.019). Conventional imaging more frequently underestimated ILC span than pMRI using a 5 mm difference threshold (24/56 (43%) versus 10/56 (18%), < 0.001), a 25% threshold (19/53 (36%) versus 10/53 (19%), = 0.035), and T category change (17/56 (30%) versus 7/56 (13%), = 0.006). Imaging-pathology size concordance was greater for MRI-described solitary masses than other lesions for both MRI and conventional imaging ( < 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, = 0.012).

Conclusion: MRI depicts pure ILC more accurately than conventional imaging and may have particular value for younger women.
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http://dx.doi.org/10.1093/jbi/wbab015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139612PMC
April 2021

Digital Mammography and Breast Tomosynthesis Performance in Women with a Personal History of Breast Cancer, 2007-2016.

Radiology 2021 08 18;300(2):290-300. Epub 2021 May 18.

From the Departments of Radiology (J.M.L., K.P.L.) and Medicine (J.M.S.), University of Washington School of Medicine, Seattle, Wash; Seattle Cancer Care Alliance, 1144 Eastlake Ave East, LG2-200, Seattle, WA 98109 (J.M.L., J.M.S., K.P.L.); Kaiser Permanente Washington Health Research Institute, Seattle, Wash (L.E.I., K.J.W., E.B., D.L.M., D.S.M.B.); Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif (K.J.W., D.S.M.B.); Department of Medicine, Division of General Internal Medicine, Department of Veterans Affairs, and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, Calif (K.K.); Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis, Calif (D.L.M.); Dartmouth Institute for Health Policy and Clinical Practice (A.N.A.T., T.O.) and Norris Cotton Cancer Center (A.N.A.T.), Geisel School of Medicine, Dartmouth College, Lebanon, NH; Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Mass (N.K.S.); Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, New South Wales, Australia (N.H.); and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah (T.O.).

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 See also the editorial by Moy and Gao in this issue.
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http://dx.doi.org/10.1148/radiol.2021204581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328154PMC
August 2021

Response to Pisano, Gastonis, Sparano, et al.

J Natl Cancer Inst 2021 Jul;113(7):940-941

Department of Public Health Sciences, University of California, Davis, CA, USA.

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http://dx.doi.org/10.1093/jnci/djab056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246926PMC
July 2021

Changes in Mammography Use by Women's Characteristics During the First 5 Months of the COVID-19 Pandemic.

J Natl Cancer Inst 2021 09;113(9):1161-1167

Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.

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.
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http://dx.doi.org/10.1093/jnci/djab045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083761PMC
September 2021

Assessment of a Risk-Based Approach for Triaging Mammography Examinations During Periods of Reduced Capacity.

JAMA Netw Open 2021 03 1;4(3):e211974. Epub 2021 Mar 1.

Department of Radiology, University of Washington School of Medicine, Seattle.

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.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.1974DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994953PMC
March 2021

Breast Magnetic Resonance Imaging Audit: Pitfalls, Challenges, and Future Considerations.

Radiol Clin North Am 2021 Jan;59(1):57-65

Department of Radiology, University of Washington School of Medicine, 1144 Eastlake Avenue East, LG-200, Seattle, WA 98109, USA.

Breast magnetic resonance (MR) imaging is the most sensitive imaging modality for breast cancer detection and guidelines recommend its use, in addition to screening mammography, for high-risk women. The most recent American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) manual coordinated cross-modality BI-RADS terminology and established an outcome monitoring section that helps guide a medical imaging outcomes audit. This article provides a framework for performing a breast MR imaging audit in clinical practice, incorporating ACR BI-RADS guidance and more recently published data, clarifies common pitfalls, and discusses audit challenges related to evolving clinical practice.
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http://dx.doi.org/10.1016/j.rcl.2020.09.002DOI Listing
January 2021

Advanced Breast Cancer Definitions by Staging System Examined in the Breast Cancer Surveillance Consortium.

J Natl Cancer Inst 2021 Jul;113(7):909-916

Department of Public Health Sciences, University of California, Davis, CA, USA.

Background: Advanced 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.

Methods: A 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.

Results: The 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.

Conclusions: Defining 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.
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http://dx.doi.org/10.1093/jnci/djaa176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491791PMC
July 2021

Trends in screening breast magnetic resonance imaging use among US women, 2006 to 2016.

Cancer 2020 12 28;126(24):5293-5302. Epub 2020 Sep 28.

Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts.

Background: Supplemental breast cancer screening with breast magnetic resonance imaging (MRI) is recommended for women at high risk of breast cancer. To the authors' knowledge, recent national trends in breast MRI use are unknown.

Methods: The authors used claims data from a large national insurer to calculate screening breast MRI rates from 2006 to 2016 in a US cohort of 10 million women aged 20 to 64 years. Use was stratified by subgroups of women with a BRCA mutation, family history of breast cancer, and prior breast cancer history and stratified by age. Joinpoint regression evaluated annual changes in trends.

Results: The total sample included 37,447 screening breast MRI examinations in 25,617 women. Overall screening breast MRI rates were low and increased from 2.9 to 12.1 examinations per 10,000 women from 2006 to 2016. MRI use in women with a BRCA mutation increased by 21% on average annually from 210.8 per 10,000 women to 1562.0 per 10,000 women from 2006 to 2016. By 2016, women aged 50 to 64 years who had a BRCA mutation had the highest use of breast MRI (1669.6 MRI examinations per 10,000 women) compared with younger women (1198.4 MRI examinations per 10,000 women, 1519.1 MRI examinations per 10,000 women, and 1567.2 MRI examinations per 10,000 women, respectively, among women aged 20-29 years, 30-39 years, and 40-49 years). Women with a BRCA mutation comprised <1% of the current study population but received approximately 9% of screening breast MRI examinations. Breast MRI rates among women with a family history of breast cancer or prior breast cancer history initially increased from 2006 to 2008, but then stabilized or decreased.

Conclusions: The increases in breast MRI use observed in the current study have indicated improvements in concordance with breast imaging guidelines. However, women with BRCA mutations remain underscreened, particularly younger women, thereby identifying a clear gap with which to enhance access.
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http://dx.doi.org/10.1002/cncr.33140DOI Listing
December 2020

Screening Performance of Digital Breast Tomosynthesis vs Digital Mammography in Community Practice by Patient Age, Screening Round, and Breast Density.

JAMA Netw Open 2020 07 1;3(7):e2011792. Epub 2020 Jul 1.

Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle.

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.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.11792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388021PMC
July 2020

Optimal Screening in Breast Cancer Survivors With Dense Breasts on Mammography.

J Clin Oncol 2020 11 24;38(33):3833-3840. Epub 2020 Jul 24.

Department of Radiology, University of Washington School of Medicine, Seattle Cancer Care Alliance, Seattle, WA.

Journal Journal of Clinical Oncology,
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http://dx.doi.org/10.1200/JCO.20.01641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676885PMC
November 2020

Surveillance for second breast cancer events in women with a personal history of breast cancer using breast MRI: a systematic review and meta-analysis.

Breast Cancer Res Treat 2020 Jun 17;181(2):255-268. Epub 2020 Apr 17.

Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave. Ste 1600, Seattle, WA, 98101, USA.

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 = 10%), recall rate (PI 5-31%; I = 97%), sensitivity (PI 58-95%; I = 47%), specificity (PI 76-97%; I = 97%), and PPV3 (PI 16-40%; I = 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.
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http://dx.doi.org/10.1007/s10549-020-05637-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262783PMC
June 2020

Breast cancer risk, worry, and anxiety: Effect on patient perceptions of false-positive screening results.

Breast 2020 Apr 13;50:104-112. Epub 2020 Feb 13.

Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA.

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.
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http://dx.doi.org/10.1016/j.breast.2020.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375679PMC
April 2020

Identifying Effective Supplemental Screening Strategies for Women with a Personal History of Breast Cancer.

Radiology 2020 04 25;295(1):64-65. Epub 2020 Feb 25.

From the Department of Radiology, University of Washington School of Medicine, 1144 Eastlake Ave E, LG-212, Seattle, WA 98109.

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http://dx.doi.org/10.1148/radiol.2020200015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104698PMC
April 2020

Facility Variability in Examination Indication Among Women With Prior Breast Cancer: Implications and the Need for Standardization.

J Am Coll Radiol 2020 Jun 28;17(6):755-764. Epub 2020 Jan 28.

Department of Radiology, University of Washington School of Medicine, Seattle, Washington.

Objective: We sought to identify and characterize examinations in women with a personal history of breast cancer likely performed for asymptomatic surveillance.

Methods: We 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.

Results: Among 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.

Conclusion: Variability 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.
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http://dx.doi.org/10.1016/j.jacr.2019.12.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275918PMC
June 2020

Patterns of Breast Imaging Use Among Women with a Personal History of Breast Cancer.

J Gen Intern Med 2019 10 13;34(10):2098-2106. Epub 2019 Aug 13.

Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.

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.
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http://dx.doi.org/10.1007/s11606-019-05181-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816668PMC
October 2019

Benefits of Supplemental Ultrasonography With Mammography-Reply.

JAMA Intern Med 2019 08;179(8):1150-1151

Department of Medicine, University of California, San Francisco.

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http://dx.doi.org/10.1001/jamainternmed.2019.2376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232785PMC
August 2019

Physician Ordering of Screening Ultrasound: National Rates and Association With State-Level Breast Density Reporting Laws.

J Am Coll Radiol 2020 Jan 18;17(1 Pt A):15-21. Epub 2019 Jul 18.

Department of Radiology, University of Washington School of Medicine, Seattle, Washington; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington. Electronic address:

Purpose: To describe factors associated with screening ultrasound ordering and determine whether adoption of state-level breast density reporting laws was associated with changes in ordering rates.

Materials And Methods: We performed a cohort study using National Ambulatory Medical Care Survey data for 2007 to 2015. We included preventive office visits for women aged 40 to 74 years without breast symptoms and signs or additional reasons requiring ultrasound ordering. Multivariate logistic regression was used to identify changes in ultrasound ordering rates pre- versus post-state-level density reporting laws, accounting for patient-, physician-, and practice-level characteristics. Analyses were weighted to account for the multistage probability sampling design of National Ambulatory Medical Care Survey.

Results: Our sample included 12,787 visits over the 9-year study period. Overall, 28.9% (3,370 of 12,787) of women underwent a breast examination and 22.1% (2,442 of 12,787) had a screening mammogram ordered. Only 3.3% (379 of 12,787) had screening ultrasound ordered. Screening ultrasounds were ordered more frequently for younger women (rate ratio [RR] 0.8 per 10-year increase in age, 95% confidence interval [CI]: 0.6-0.9, P = .003) and at urban practices (RR 2.3, 95% CI: 1.1-5.0, P = .028), and less frequently in practices with computer reminders for ordering screening tests (RR 0.6, 95% CI: 0.3-0.9, P = .024). In multivariate analyses, the rate of ultrasound ordering did not change after adoption of density notification laws (RR 0.7, 95% CI: 0.3-2.0, P = .57).

Conclusion: The rate of screening ultrasound ordering remains low over time. There was no observed association between adoption of state-level density reporting laws and overall changes in ultrasound ordering.
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http://dx.doi.org/10.1016/j.jacr.2019.07.002DOI Listing
January 2020

Patterns of Surveillance Advanced Imaging and Serum Tumor Biomarker Testing Following Launch of the Choosing Wisely Initiative.

J Natl Compr Canc Netw 2019 07;17(7):813-820

Department of Radiology, University of Washington Medical Center.

Background: The purpose of this study was to assess advanced imaging (bone scan, CT, or PET/CT) and serum tumor biomarker use in asymptomatic breast cancer survivors during the surveillance period.

Patients And Methods: Cancer registry records for 2,923 women diagnosed with primary breast cancer in Washington State between January 1, 2007, and December 31, 2014, were linked with claims data from 2 regional commercial insurance plans. Clinical data including demographic and tumor characteristics were collected. Evaluation and management codes from claims data were used to determine advanced imaging and serum tumor biomarker testing during the peridiagnostic and surveillance phases of care. Multivariable logistic regression models were used to identify clinical factors and patterns of peridiagnostic imaging and biomarker testing associated with surveillance advanced imaging.

Results: Of 2,923 eligible women, 16.5% (n=480) underwent surveillance advanced imaging and 31.8% (n=930) received surveillance serum tumor biomarker testing. Compared with women diagnosed before the launch of the Choosing Wisely campaign in 2012, later diagnosis was associated with lower use of surveillance advanced imaging (odds ratio [OR], 0.68; 95% CI, 0.52-0.89). Factors significantly associated with use of surveillance advanced imaging included increasing disease stage (stage III: OR, 3.65; 95% CI, 2.48-5.38), peridiagnostic advanced imaging use (OR, 1.76; 95% CI, 1.33-2.31), and peridiagnostic serum tumor biomarker testing (OR, 1.35; 95% CI, 1.01-1.80).

Conclusions: Although use of surveillance advanced imaging in asymptomatic breast cancer survivors has declined since the launch of the Choosing Wisely campaign, frequent use of surveillance serum tumor biomarker testing remains prevalent, representing a potential target for further efforts to reduce low-value practices.
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http://dx.doi.org/10.6004/jnccn.2018.7281DOI Listing
July 2019

The Impact of Preoperative Breast MRI on Surgical Management of Women with Newly Diagnosed Ductal Carcinoma In Situ.

Acad Radiol 2020 04 5;27(4):478-486. Epub 2019 Jul 5.

Department of Radiology, University of Washington School of Medicine, Seattle Cancer Care Alliance, 1144 Eastlake Avenue East, LG2-200, Seattle, WA 98109.

Rationale And Objectives: Use of preoperative breast MRI (pMRI) to evaluate ductal carcinoma in situ (DCIS) extent is controversial due to limited data on its impact on surgical management. We sought to evaluate the effect of pMRI on surgical management of women with core needle biopsy (CNB)-diagnosed pure DCIS at a multidisciplinary academic institution.

Materials And Methods: This retrospective study included all women with CNB-diagnosed DCIS (1/2004-12/2013) without prior ipsilateral breast cancer and who underwent surgery within 180 days of diagnosis. Patient features, number of CNBs and surgeries, and single successful breast conserving surgery (BCS) rate were compared between pMRI and no-pMRI cohorts. Number of surgeries and single BCS success rates were also compared to published US (SEER) and Danish National Registry data.

Results: Among the 373 women included, no clinical differences were identified between the pMRI (n = 332) and no-pMRI (n = 41) cohorts (p > 0.05). The pMRI group experienced a higher additional CNB rate (30% vs. 7%, p = 0.002) but fewer total surgeries (mean = 1.2 vs. 1.5, p < 0.001) than the no-pMRI group. Among the 245 women for whom BCS was attempted, the pMRI cohort underwent fewer mean surgeries (1.3 vs. 1.7, p < 0.001) with a greater single successful BCS rate (77% vs. 43%, p < 0.001). Compared to published data, women with pMRI who underwent BCS experienced fewer surgeries (difference (Δ) = -0.22 vs. -0.17, p < 0.001) with a higher single successful BCS rate (Δ = +20% vs. +14%, p < 0.001).

Conclusion: pMRI may improve surgical management of DCIS at multidisciplinary centers with breast cancer specialists.
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http://dx.doi.org/10.1016/j.acra.2019.05.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942628PMC
April 2020

Surveillance Breast MRI and Mammography: Comparison in Women with a Personal History of Breast Cancer.

Radiology 2019 08 4;292(2):311-318. Epub 2019 Jun 4.

From the Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101 (K.J.W., L.I., D.S.M.B., S.D.B., M.B., D.J., D.L.M.); Departments of Medicine and Epidemiology and Biostatistics, General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, San Francisco, Calif (K.K.); Department of Radiology, University of North Carolina, Chapel Hill, NC (L.M.H.); Department of Medicine, Brigham and Women's Hospital, Boston, Mass (L.N.); Department of Biomedical Data Science, Norris Cotton Cancer Center, Dartmouth Medical School, Hanover, NH (T.O.); Departments of Surgery and Radiology, University of Vermont, Burlington, Vt (B.L.S.); Department of Radiology, University of Washington, Seattle Cancer Care Alliance Seattle, Wash (J.M.L.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.); Department of Public Health Sciences, University of California, Davis, Davis, Calif (D.L.M.).

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 ( = 11 745) or breast MRI ( = 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; < .001) and cancer detection rate (OR, 1.7; 95% CI: 1.1, 2.7; = .03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI: 0.4, 2.9; = .84) or interval cancer rate (OR, 1.1; 95% CI: 0.6, 2.2; = .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 See also the editorial by Newell in this issue.
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http://dx.doi.org/10.1148/radiol.2019182475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694722PMC
August 2019

Performance of Screening Ultrasonography as an Adjunct to Screening Mammography in Women Across the Spectrum of Breast Cancer Risk.

JAMA Intern Med 2019 05;179(5):658-667

Kaiser Permanente Washington Health Research Institute, Seattle.

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.
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http://dx.doi.org/10.1001/jamainternmed.2018.8372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503561PMC
May 2019

Double reading of automated breast ultrasound with digital mammography or digital breast tomosynthesis for breast cancer screening.

Clin Imaging 2019 May - Jun;55:119-125. Epub 2019 Jan 23.

Massachusetts General Hospital, Department of Radiology, 15 Parkman St., Boston, MA 02114, United States of America.

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.
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http://dx.doi.org/10.1016/j.clinimag.2019.01.019DOI Listing
November 2019

Re: "Linkage of the ACR National Mammography Database to the Network of State Cancer Registries: Proof of Concept Evaluation by the ACR National Mammography Database Committee".

J Am Coll Radiol 2019 02;16(2):135-136

Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, California; General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, California.

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http://dx.doi.org/10.1016/j.jacr.2018.09.056DOI Listing
February 2019

Population-Based Assessment of the Association Between Magnetic Resonance Imaging Background Parenchymal Enhancement and Future Primary Breast Cancer Risk.

J Clin Oncol 2019 04 9;37(12):954-963. Epub 2019 Jan 9.

2 University of California, San Francisco, San Francisco, CA.

Purpose: To evaluate comparative associations of breast magnetic resonance imaging (MRI) background parenchymal enhancement (BPE) and mammographic breast density with subsequent breast cancer risk.

Patients And Methods: We 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.

Results: Among 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% 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 ( = .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).

Conclusion: BPE 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.
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http://dx.doi.org/10.1200/JCO.18.00378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494266PMC
April 2019

Impact of New Technology Adoption on Breast Cancer Screening.

Radiology 2019 Mar 11;290(3):638-639. Epub 2018 Dec 11.

From the Department of Radiology, University of Washington School of Medicine, 1144 Eastlake Ave E, LG-212, Seattle, Wash 98109 (C.I.L., J.M.L.); Hutchinson Institute for Cancer Outcomes Research, Seattle, Wash (C.I.L., J.M.L.); and Department of Health Services, University of Washington School of Public Health, Seattle, Wash (C.I.L.).

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http://dx.doi.org/10.1148/radiol.2018182476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394733PMC
March 2019

Predictors of surveillance mammography outcomes in women with a personal history of breast cancer.

Breast Cancer Res Treat 2018 Aug 10;171(1):209-215. Epub 2018 May 10.

Department of Radiology, Seattle Cancer Care Alliance, University of Washington School of Medicine, Seattle, WA, USA.

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.
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http://dx.doi.org/10.1007/s10549-018-4808-9DOI Listing
August 2018

Cumulative Risk Distribution for Interval Invasive Second Breast Cancers After Negative Surveillance Mammography.

J Clin Oncol 2018 07 2;36(20):2070-2077. Epub 2018 May 2.

Janie M. Lee and Diana L. Lam, University of Washington, and Seattle Cancer Care Alliance; Linn Abraham, Diana S.M. Buist, and Diana L. Miglioretti, Kaiser Permanente Washington Health Research Institute, Seattle, WA; Karla Kerlikowske, Department of Veterans Affairs, University of California, San Francisco, San Francisco; Diana L. Miglioretti, University of California, Davis, Davis, CA; Nehmat Houssami, University of Sydney, Sydney, New South Wales, Australia; Constance D. Lehman, Massachusetts General Hospital, Boston, MA; Louise M. Henderson, University of North Carolina, Chapel Hill, Chapel Hill, NC; and Rebecca A. Hubbard, University of Pennsylvania, Philadelphia, PA.

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 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.
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http://dx.doi.org/10.1200/JCO.2017.76.8267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036621PMC
July 2018

Proposing New RadLex Terms by Analyzing Free-Text Mammography Reports.

J Digit Imaging 2018 10;31(5):596-603

Department of Radiology and Department of Biomedical Data Science, Medical School Office Building (MSOB), Stanford University, 1265 Welch Road, X383, Stanford, CA, 94305-5464, USA.

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.
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http://dx.doi.org/10.1007/s10278-018-0064-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6148814PMC
October 2018
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