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Purpose: The Ugandan Ministry of Health adopted BI-RADS as standard of care in 2016. The authors performed a medical audit of breast ultrasound practices at four tertiary-level hospitals to assess interpretive performance. The authors also determined the effect of a low-cost navigation program linking breast imaging and pathology on the percentage of patients completing diagnostic care., Methods: The authors retrieved 966 consecutive diagnostic breast ultrasound reports, with complete data, for studies performed on women aged >18 years presenting with symptoms of breast cancer between 2018 and 2020 from participating hospitals. Ultrasound results were linked to tumor registries and patient follow-up. A medical audit was performed according to the ACR's BI-RADS Atlas, fifth edition, and results were compared with those of a prior audit performed in 2013. At Mulago Hospital, an intervention was piloted on the basis of patient navigation, cost sharing, and same-day imaging, tissue sampling, and pathology., Results: In total, 888 breast ultrasound examinations (91.9%) were eligible for inclusion. Compared with 2013, the postintervention cancer detection rate increased from 38 to 148.7 cancers per 1,000 examinations, positive predictive value 2 from 29.6% to 48.9%, and positive predictive value 3 from 62.7% to 79.9%. Specificity decreased from 90.5% to 87.7% and sensitivity from 92.3% to 81.1%. The mean time from tissue sampling to receipt of a diagnosis decreased from 60 to 7 days. The intervention increased the percentage of patients completing diagnostic care from 0% to 100%., Conclusions: Efforts to establish a culture of continuous quality improvement in breast ultrasound require robust data collection that links imaging results to pathology and patient follow-up. Interpretive performance met BI-RADS benchmarks for palpable masses, except sensitivity. This resource-appropriate strategy linking imaging, tissue sampling, and pathology interpretation decreased time to diagnosis and rates of loss to follow-up and improved the precision of the audit., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background Contrast-enhanced mammography (CEM) and abbreviated breast MRI (ABMRI) are emerging alternatives to standard MRI for supplemental breast cancer screening. Purpose To compare the diagnostic performance of CEM, ABMRI, and standard MRI. Materials and Methods This single-institution, prospective, blinded reader study included female participants referred for breast MRI from January 2018 to June 2021. CEM was performed within 14 days of standard MRI; ABMRI was produced from standard MRI images. Two readers independently interpreted each CEM and ABMRI after a washout period. Examination-level performance metrics calculated were recall rate, cancer detection, and false-positive biopsy recommendation rates per 1000 examinations and sensitivity, specificity, and positive predictive value of biopsy recommendation. Bootstrap and permutation tests were used to calculate 95% CIs and compare modalities. Results Evaluated were 492 paired CEM and ABMRI interpretations from 246 participants (median age, 51 years; IQR, 43-61 years). On 49 MRI scans with lesions recommended for biopsy, nine lesions showed malignant pathology. No differences in ABMRI and standard MRI performance were identified. Compared with standard MRI, CEM demonstrated significantly lower recall rate (14.0% vs 22.8%; difference, -8.7%; 95% CI: -14.0, -3.5), lower false-positive biopsy recommendation rate per 1000 examinations (65.0 vs 162.6; difference, -97.6; 95% CI: -146.3, -50.8), and higher specificity (87.8% vs 80.2%; difference, 7.6%; 95% CI: 2.3, 13.1). Compared with standard MRI, CEM had significantly lower cancer detection rate (22.4 vs 36.6; difference, -14.2; 95% CI: -28.5, -2.0) and sensitivity (61.1% vs 100%; difference, -38.9%; 95% CI: -66.7, -12.5). The performance differences between CEM and ABMRI were similar to those observed between CEM and standard MRI. Conclusion ABMRI had comparable performance to standard MRI and may support more efficient MRI screening. CEM had lower recall and higher specificity compared with standard MRI or ABMRI, offset by lower cancer detection rate and sensitivity compared with standard MRI. These trade-offs warrant further consideration of patient population characteristics before widespread screening with CEM. Clinical trial registration no. NCT03517813 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Chang in this issue.

Imaging plays a vital role in managing patients undergoing neoadjuvant chemotherapy, as treatment decisions rely heavily on accurate assessment of response to therapy. This document provides evidence-based guidelines for imaging breast cancer before, during, and after initiation of neoadjuvant chemotherapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

African American (AA) women experience much greater mortality due to breast cancer (BC) than non-Latino Whites (NLW). Clinical patient navigation is an evidence-based strategy used by healthcare institutions to improve AA women's breast cancer outcomes. While empirical research has demonstrated the potential effect of navigation interventions for individuals, the population-level impact of navigation on screening, diagnostic completion, and stage at diagnosis has not been assessed. An agent-based model (ABM), representing 50-74-year-old AA women and parameterized with locally sourced data from Chicago, is developed to simulate screening mammography, diagnostic resolution, and stage at diagnosis of cancer. The ABM simulated three counterfactual scenarios: (1) a control setting without any navigation that represents the "standard of care"; (2) a clinical navigation scenario, where agents receive navigation from hospital-affiliated staff; and (3) a setting with network navigation, where agents receive clinical navigation and/or social network navigation (i.e., receiving support from clinically navigated agents for breast cancer care). In the control setting, the mean population-level screening mammography rate was 46.3% (95% CI: 46.2%, 46.4%), the diagnostic completion rate was 80.2% (95% CI: 79.9%, 80.5%), and the mean early cancer diagnosis rate was 65.9% (95% CI: 65.1%, 66.7%). Simulation results suggest that network navigation may lead up to a 13% increase in screening completion rate, 7.8% increase in diagnostic resolution rate, and a 4.9% increase in early-stage diagnoses at the population-level. Results suggest that systems science methods can be useful in the adoption of clinical and network navigation policies to reduce breast cancer disparities., (© 2022. The New York Academy of Medicine.)

Breast cancer is the second most common cancer in Peruvian women. Due to limitations in national breast cancer screening programs, especially in rural areas, more than 50% of cases of breast cancer in Peru are diagnosed in advanced stages. In collaboration with a local clinic registered as a nongovernmental organization (CerviCusco), RAD-AID International aims to create a sustainable diagnostic structure to improve breast cancer screening in Cuzco. With the support of local, national, and international partners that have collaborated in analyzing radiological resources, raising awareness in the population, acquiring equipment, training clinical staff, and building referral networks, our teams of radiologists, included in the RAD-AID team, have participated in training CerviCusco staff in breast ultrasound, thus enabling additional training for radiology residents through a regulated international collaboration., (Copyright © 2021 SERAM. All rights reserved.)

Purpose To examine the clinical value of multiband (MB) sensitivity encoding (SENSE)-accelerated diffusion-weighted imaging (DWI) for breast imaging by performing quantitative and qualitative comparisons with conventional diffusion-weighted echo-planar imaging, or conventional DWI (cDWI). Materials and Methods In this prospective study (ClinicalTrials.gov identifier NCT03607552), women with breast cancer were recruited from July 2018 to July 2019 to undergo additional MB SENSE DWI during clinical 3-T breast MRI examinations. The cDWI and MB SENSE DWI acquisitions were assessed both quantitatively and qualitatively. Regions of interest were defined for tumorous and normal tissue, and the tumor apparent diffusion coefficient (ADC), contrast-to-noise ratio (CNR), and signal index (SI) were calculated for both DWI methods. Three readers independently reviewed the two acquisitions side by side and provided relative image quality scores. Tumor ADC, CNR, and SI measures were compared between cDWI and MB SENSE DWI acquisitions by using a paired t test, and reader preferences were evaluated by using the sign test. Results The study included 38 women (median age, 48 years; range, 28-83 years). Overall agreement was good between cDWI and MB SENSE DWI tumor ADC measures (intraclass correlation coefficient, 0.87 [95% CI: 0.75, 0.94]), and no differences were evident in the ADC (median, 0.93 × 10 -3 mm 2 /sec vs 0.87 ×10 -3 mm 2 /sec; P = .50), CNR (2.2 vs 2.3; P = .17), or SI (9.2 vs 9.2; P = .23) measurements. The image quality of cDWI and MB SENSE DWI acquisitions were considered equal for 51% of images (58 of 114), whereas MB SENSE DWI was preferred more often than cDWI (37% [42 of 114] vs 12% [14 of 114]; P < .001). The preference for MB SENSE DWI was most often attributed to better fat suppression. Conclusion MB SENSE can be used to accelerate breast DWI acquisition times without compromising the image quality or the fidelity of quantitative ADC measurements. Keywords: MR-Diffusion-weighted Imaging, Breast, Comparative Studies, Technology Assessment Clinical trial registration no. NCT03607552 © RSNA, 2022.

Mammography remains the only validated screening tool for breast cancer, however, there are limitations to mammography. One of the limitations of mammography is the variable sensitivity based on breast density. Supplemental screening may be considered based on the patient's risk level and breast density. For average-risk women with nondense breasts, the sensitivity of digital breast tomosynthesis (DBT) screening is high; additional supplemental screening is not warranted in this population. For average-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhanced mammography, screening ultrasound (US), breast MRI, or abbreviated breast MRI. In intermediate-risk women, there is emerging evidence suggesting that women in this population may benefit from breast MRI or abbreviated breast MRI. In intermediate-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhancedmammography or screening US. There is strong evidence supporting screening high-risk women with breast MRI regardless of breast density. Contrast-enhanced mammography, whole breast screening US, or abbreviated breast MRI may be also considered. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: On unenhanced diffusion-weighted imaging (DWI), computing or synthesizing high b-value images from lower b-value acquisitions can enhance breast cancer visibility. This study aimed to evaluate relative lesion conspicuity on computed versus acquired diffusion-weighted images and investigate clinical characteristics influencing optimal b-values., Materials and Methods: Women with newly diagnosed breast cancer were prospectively enrolled and underwent 3T breast MRI with DWI. Lesion contrast-to-noise ratio (CNR) was measured across a range of b-values (0-2500 s/mm 2 ) for computed and acquired DWI. Three readers independently compared lesion visibility between computed and acquired DWI and selected the optimal b-value. Computed versus acquired DWI was compared quantitatively based on CNR by paired t-test and qualitatively based on reader preference using a sign test. Optimal b-values by qualitative and quantitative assessment were compared by paired t-test, and associations with clinical characteristics were assessed by Wilcoxon rank sum test., Results: The study included 30 women (median age, 48 years); 28 with invasive carcinoma, 2 DCIS. Lesion CNR was higher on acquired versus computed images (p = 0.018), while lesion visibility by reader assessment was not different (p = 0.36). Optimal b-values selected by readers (mean, b = 1411 ± 383 s/mm 2 ) were slightly higher than those based on peak CNR (b = 1233 ± 463 s/mm 2 , p = 0.023), and were higher for younger (≤50 years) versus older women (p = 0.002) and dense versus nondense breasts (p = 0.015)., Conclusion: Lesion CNR on computed high b-value images was slightly reduced versus acquired images, but our study suggests that this did not significantly impact lesion visibility. Computing high b-value images offers extra flexibility to adjust b-value during interpretation., (Copyright © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

To evaluate the diagnostic impact of point-of-care breast ultrasound by trained primary care physicians (PCPs) as part of a breast cancer detection program using clinical breast exam in an underserved region of Peru. Medical records and breast ultrasound images of symptomatic women presenting to the Breast Cancer Detection Model (BCDM) in Trujillo, Peru were collected from 2017-2018. Performance was measured against final outcomes derived from regional cancer center medical records, fine needle aspiration results, patient follow-up (sensitivity, specificity, positive, and negative predictive values), and by percent agreement with the retrospective, blinded interpretation of images by a fellowship-trained breast radiologist, and a Peruvian breast surgeon. The diagnostic impact of ultrasound, compared to clinical breast exam (CBE), was calculated for actual practice and for potential impact of two alternative reporting systems. Of the 171 women presenting for breast ultrasound, 23 had breast cancer (13.5%). Breast ultrasound used as a triage test (current practice) detected all cancer cases (including four cancers missed on confirmatory CBE). PCPs showed strong agreement with radiologist and surgeon readings regarding the final management of masses (85.4% and 80.4%, respectively). While the triage system yielded a similar number of biopsies as CBE alone, using the condensed and full BI-RADS systems would have reduced biopsies by 60% while identifying 87% of cancers immediately and deferring 13% to six-month follow-up. Point-of-care ultrasound performed by trained PCPs improves diagnostic accuracy for managing symptomatic women over CBE alone and enhances access. Greater use of BI-RADS to guide management would reduce the diagnostic burden substantially., Competing Interests: The authors have declared that no competing interests exist.

Background: Successful breast cancer detection programs rely on standardized reporting and interpreting systems, such as the Breast Imaging Reporting and Data System (BI-RADS), to improve system performance. In low-income and middle-income countries, evolving diagnostic programs have insufficient resources to either fully implement BI-RADS or to periodically evaluate the program's performance, which is a necessary component of BI-RADS. This leads to inconsistent breast ultrasound interpretation and a failure to improve performance., Methods: The authors applied the Breast Health Global Initiative's phased implementation strategy to implement diagnostic ultrasound and BI-RADS within the context of a limited-resource setting., Results: The authors recommended starting with triage ultrasound to distinguish suspicious masses from normal breast tissue and benign masses such as cysts because the majority of health workers performing ultrasounds at this level have minimal breast imaging experience. Transitioning to full diagnostic ultrasound with condensed or full BI-RADS should occur after performance and quality metrics have been met., Conclusions: Transitioning through these phases across facilities likely will occur at different times, particularly in rural versus urban settings., (© 2020 American Cancer Society.)

Background: Greater than 80% of women presenting for breast cancer treatment in Uganda have late-stage disease, which is attributable to a dysfunctional referral system and a lack of recognition of the early signs and symptoms among primary health care providers, and compounded by the poor infrastructure and inadequate human capacity. Improving the breast health care system requires a systemic approach beginning with situational analysis to identify systematic gaps that prevent sustainable improvements in outcome., Methods: The authors performed a situational analysis of the breast health care system using methods developed by the Breast Health Global Initiative. Based on their findings, they developed a series of recommendations for strengthening the health system for the early diagnosis of breast cancer based on clinical detection, referral, tissue sampling, and diagnosis., Results: Deficits in the recognition of breast cancer signs and symptoms, the underuse of clinical breast examination as a diagnostic and/or screening tool, the centralization of diagnostic tests (radiology and pathology), reliance on excisional biopsies rather than needle biopsies, and a lack of trained professionals and knowledge of the referral system all contribute to significant health system delays., Conclusions: To strengthen referral networks and improve the early diagnosis of breast cancer in Uganda, national referral hospitals should provide educational programs to primary health care providers in community health centers (CHCs), at which the majority of women first present with symptoms. At secondary district-level facilities in which imaging and tissue sampling can be performed, the capacity for diagnostic testing could be increased through task shifting of basic interpretation (abnormal vs normal) from specialists to nonspecialists using networking technology to facilitate remote oversight from specialists at the national referral hospitals., (© 2020 American Cancer Society.)

Background: Implementation of evidence-based, resource-appropriate guidelines for breast cancer control should be preceded by a baseline assessment or situational analysis to assess breast health infrastructure, workforce capacity, patient pathways, existing practices, accessibility, and costs., Methods: To support the assessment of breast health care systems within the broader context in which they exist, the Breast Health Global Initiative (BHGI) developed, tested, and refined a set of situational analysis tools with which to guide the assessment of breast health care capacity, identify the relative strengths and weaknesses of the health system, and support stakeholders in prioritizing actionable items to advance breast cancer care using evidence-based strategies tailored to their setting. The tools address 6 domains of breast health care delivery: 1) breast cancer early detection practices; 2) breast cancer awareness programs; 3) the availability of breast cancer surgery; 4) the availability of pathology; 5) the availability of radiotherapy, and 6) the availability of systemic therapy services. The current study also describes the more comprehensive International Atomic Energy Agency Programme of Action for Cancer Therapy (PACT) integrated missions for PACT (imPACT) review., Results: As of 2020, 5 formal BHGI situational analyses have been performed in India, Brazil, Panama, Tanzania, and Uganda. As of August 2019, a total of 100 imPACT reviews have been conducted in 91 countries. These assessments can contribute to more informed policymaking., Conclusions: Situational analyses are a prerequisite for the development of resource-appropriate strategies with which to advance breast cancer control in any setting and should assess services across the entire breast health care continuum as well as the broader structural, sociocultural, personal, and financial contexts within which they operate., (© 2020 American Cancer Society.)

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered., (© 2020 American Cancer Society.)

As the proportion of women diagnosed with early stage breast cancer increases, the role of imaging for staging and surveillance purposes is considered. National and international guidelines discourage the use of staging imaging for asymptomatic patients newly diagnosed with stage 0 to II breast cancer, even if there is nodal involvement, as unnecessary imaging can delay care and affect outcomes. In asymptomatic patients with a history of stage I breast cancer that received treatment for curative intent, there is no role for imaging to screen for distant recurrences. However, routine surveillance with an annual mammogram is the only imaging test that should be performed to detect an in-breast recurrence or a new primary breast cancer in women with a history of stage I breast cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Most women with breast cancer in sub-Saharan Africa (SSA) are diagnosed with late-staged disease. The current study assesses patient-related barriers among women from a general SSA population to better understand how patient-related barriers contribute to diagnostic delays. Using convenience-based sampling, 401 Ugandan women without breast cancer were surveyed to determine how prior participation in cancer detection practices correlate with patient-related barriers to prompt diagnosis. In a predominantly poor (76%) and rural population (75%), the median age of the participants was 38. Of the women surveyed, 155 (46%) had prior exposure to breast cancer education, 92 (27%) performed breast self-examination (BSE) and 68 (20%) had undergone a recent clinical breast examination (CBE), breast ultrasound or breast biopsy. The most commonly identified barriers to prompt diagnosis were knowledge deficits regarding early diagnosis (79%), economic barriers to accessing care (68%), fear (37%) and poor social support (24%). However, only women who reported knowledge deficits-a modifiable barrier-were less likely to participate in cancer detection practices (p<0.05). Women in urban and rural areas were similarly likely to report economic barriers, knowledge deficits and/or poor social support, but rural women were less likely than urban women to have received breast cancer education and/or perform BSE (p<0.001). Women who have had prior breast cancer education (p<0.001) and/or who perform BSE (p = 0.02) were more likely to know where she can go to receive a diagnostic breast evaluation. These findings suggest that SSA countries developing early breast cancer detection programs should specifically address modifiable knowledge deficits among women less likely to achieve a diagnostic work-up to reduce diagnostic delays and improve breast cancer outcomes., Competing Interests: The authors have declared that no competing interests exist.

Background: The purpose of this study is to determine the role of family obligation stress on Ugandan women's participation in preventive breast health through the receipt of breast cancer education and health check-ups., Materials and Methods: A validated survey was conducted on a community sample of Ugandan women, providing a multi-item scale to assess preventive breast-health-seeking behaviors and measure family obligation stress (FO; range 6-18). Univariate and multivariate linear regression was used to assess associations between sociodemographic factors and FO. Univariate and multivariate linear regression (used in conjunction with the robust sandwich estimator for standard errors) and probability differences (PDs) were used to evaluate associations between preventive breast-health-seeking behaviors, sociodemographic factors, and FO., Results: A total of 401 Ugandan women ages 25-74 participated in the survey. Most had three or more children in the home (60%) and were employed full time (69%). Higher FO was associated with increasing number of children and/or adults in the household ( p  < .05), full-time employment ( p  < .001), and being single ( p  = .003). Women with higher FO were less likely to participate in breast cancer education (PD = -0.02 per 1-point increase, p  = .008) and preventive health check-ups (PD = -0.02, p  = .018), associations that persisted on multivariate analysis controlling for sociodemographic factors., Conclusion: Ugandan women with high FO are less likely to participate in preventive breast cancer detection efforts including breast cancer education and preventive health check-ups. Special efforts should be made to reach women with elevated FO, because it may be a risk factor for late-stage presentation among women who develop breast cancer., Implications for Practice: High family obligation stress (FO) significantly reduces women's participation in preventive health check-ups and breast cancer education. These findings support research in U.S. Latinas showing high FO negatively affects women's health, suggesting that FO is an important factor in women's health-seeking behavior in other cultures. Addressing family obligation stress by including family members involved in decision-making is essential for improving breast cancer outcomes in low- and middle-income countries, such as Uganda., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2018.)

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

Purpose: To assess breast cancer beliefs in Uganda and determine whether these beliefs are associated with factors potentially related to nonparticipation in early detection., Methods: A survey with open- and close-ended items was conducted in a community sample of Ugandan women to assess their beliefs about breast cancer. Linear regression was used to ascertain associations between breast cancer beliefs and demographic factors potentially associated with early detection, including socioeconomic factors, health care access, prior breast cancer knowledge, and personal detection practices., Results: Of the 401 Ugandan women surveyed, most had less than a primary school education and received medical care at community health centers. Most women either believed in or were unsure about cultural explanatory models for developing breast cancer (> 82%), and the majority listed these beliefs as the most important causes of breast cancer (69%). By comparison, ≤ 45% of women believed in scientific explanatory risks for developing breast cancer. Although most believed that regular screening and early detection would find breast cancer when it is easy to treat (88% and 80%, respectively), they simultaneously held fatalistic attitudes toward their own detection efforts, including belief or uncertainty that a cure is impossible once they could self-detect a lump (54%). Individual beliefs were largely independent of demographic factors., Conclusion: Misconceptions about breast cancer risks and benefits of early detection are widespread in Uganda and must be addressed in future breast cancer awareness efforts. Until screening programs exist, most breast cancer will be self-detected. Unless addressed by future awareness efforts, the high frequency of fatalistic attitudes held by women toward their own detection efforts will continue to be deleterious to breast cancer early detection in sub-Saharan countries like Uganda.

Objective: The objective of our study was to determine the accuracy of preoperative measurements for detecting pathologic complete response (CR) and assessing residual disease after neoadjuvant chemotherapy (NACT) in patients with locally advanced breast cancer., Subjects and Methods: The American College of Radiology Imaging Network 6657 Trial prospectively enrolled women with ≥ 3 cm invasive breast cancer receiving NACT. Preoperative measurements of residual disease included longest diameter by mammography, MRI, and clinical examination and functional volume on MRI. The accuracy of preoperative measurements for detecting pathologic CR and the association with final pathology size were assessed for all lesions, separately for single masses and nonmass enhancements (NMEs), multiple masses, and lesions without ductal carcinoma in situ (DCIS)., Results: In the 138 women with all four preoperative measures, longest diameter by MRI showed the highest accuracy for detecting pathologic CR for all lesions and NME (AUC = 0.76 and 0.84, respectively). There was little difference across preoperative measurements in the accuracy of detecting pathologic CR for single masses (AUC = 0.69-0.72). Longest diameter by MRI and longest diameter by clinical examination showed moderate ability for detecting pathologic CR for multiple masses (AUC = 0.78 and 0.74), and longest diameter by MRI and longest diameter by mammography showed moderate ability for detecting pathologic CR for tumors without DCIS (AUC = 0.74 and 0.71). In subjects with residual disease, longest diameter by MRI exhibited the strongest association with pathology size for all lesions and single masses (r = 0.33 and 0.47). Associations between preoperative measures and pathology results were not significantly influenced by tumor subtype or mammographic density., Conclusion: Our results indicate that measurement of longest diameter by MRI is more accurate than by mammography and clinical examination for preoperative assessment of tumor residua after NACT and may improve surgical planning.

Purpose: Mobile mammographic services have been proposed as a way to reduce Latinas' disproportionate late-stage presentation compared with white women by increasing their access to mammography. The aims of this study were to assess why Latinas may not use mobile mammographic services and to explore their preferences after using these services., Methods: Using a mixed-methods approach, a secondary analysis was conducted of baseline survey data (n = 538) from a randomized controlled trial to improve screening mammography rates among Latinas in Washington. Descriptive statistics and bivariate regression were used to characterize mammography location preferences and to test for associations with sociodemographic indices, health care access, and perceived breast cancer risk and beliefs. On the basis of these findings, a qualitative study (n = 18) was used to explore changes in perceptions after using mobile mammographic services., Results: More Latinas preferred obtaining a mammogram at a fixed facility (52.3% [n = 276]) compared with having no preference (46.3% [n = 249]) and preferring mobile mammographic services (1.7% [n = 9]). Concerns about privacy and comfort (15.6% [n = 84]) and about general quality (10.6% [n = 57]) were common reasons for preferring a fixed facility. Those with no history of mammography preferred a fixed facility (P < .05). In the qualitative study, Latinas expressed similar initial concerns but became positive toward the mobile mammographic services after obtaining a mammogram., Conclusions: Although most Latinas preferred obtaining a mammogram at a fixed facility, positive experiences with mobile mammography services changed their attitudes toward them. These findings highlight the need to include community education when using mobile mammographic service to increase screening mammography rates in underserved communities., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Breast cancer incidence and mortality rates continue to rise in Peru, with related deaths projected to increase from 1208 in 2012, to 2054 in 2030. Despite improvements in national cancer control plans, various barriers to positive breast cancer outcomes remain. Multiorganisational stakeholder collaboration is needed for the development of functional, sustainable early diagnosis, treatment and supportive care programmes with the potential to achieve measurable outcomes. In 2011, PATH, the Peruvian Ministry of Health, the National Cancer Institute in Lima, and the Regional Cancer Institute in Trujillo collaborated to establish the Community-based Program for Breast Health, the aim of which was to improve breast health-care delivery in Peru. A four-step, resource-stratified implementation strategy was used to establish an effective community-based triage programme and a practical early diagnosis scheme within existing multilevel health-care infrastructure. The phased implementation model was initially developed by the Breast Cancer Initiative 2·5: a group of health and non-governmental organisations who collaborate to improve breast cancer outcomes. To date, the Community-based Program for Breast Health has successfully implemented steps 1, 2, and 3 of the Breast Cancer Initiative 2·5 model in Peru, with reports of increased awareness of breast cancer among women, improved capacity for early diagnosis among health workers, and the creation of stronger and more functional linkages between the primary levels (ie, local or community) and higher levels (ie, district, region, and national) of health care. The Community-based Program for Breast Health is a successful example of stakeholder and collaborator involvement-both internal and external to Peru-in the design and implementation of resource-appropriate interventions to increase breast health-care capacity in a middle-income Latin American country., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose/objectives: To understand the relationship between mammography history and current thoughts about obtaining a mammogram among Latinas and examine the mediation effects of several healthcare factors.
., Design: Cross-sectional survey.
., Setting: Federally qualified health centers (Sea Mar Community Health Centers) in western Washington.
., Sample: 641 Latinas nonadherent and adherent with screening mammography.
., Methods: Baseline survey data from Latinas with a mammography history of never, not recent (more than two years), or recent (less than two years) were analyzed. Preacher and Hayes methods were used to estimate the mediation effect of healthcare factors.
., Main Research Variables: The survey assessed mammography history, sociodemographic and healthcare factors, and current thoughts about obtaining a mammogram.
., Findings: Latinas' thoughts about obtaining a mammogram were associated with mammography history. Having had a clinical breast examination mediated 70% of differences between Latinas with a never and recent mammography history. Receipt of a provider recommendation mediated 54% of differences between Latinas with and without a recent mammography history.
., Conclusions: These findings emphasize the importance of the patient-provider relationship during a clinic visit and help inform how nurses may be incorporated into subsequent screening mammography interventions tailored to Latinas.
., Implications for Nursing: As providers, health educators, and researchers, nurses have critical roles in encouraging adherence to screening mammography guidelines among Latinas.

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

Rationale and Objectives: This study aimed to determine whether a 2-day educational course using a condensed Breast Imaging Reporting and Data System (condensed BI-RADS) improved the accuracy of Ugandan healthcare workers interpreting breast ultrasound., Materials and Methods: The target audience of this intervention was Ugandan healthcare workers involved in performing, interpreting, or acting on the results of breast ultrasound. The educational course consisted of a pretest knowledge assessment, a series of lectures on breast imaging interpretation and standardized reporting using a condensed BI-RADS, and a posttest knowledge assessment. Participants interpreted 53 different ultrasound test cases by selecting the finding type, descriptors for masses, and recommendations. We compared the percent correct on the pretest and posttest based on occupation and training level., Results: Sixty-one Ugandan healthcare workers participated in this study, including 13 radiologists, 13 other physicians, 12 technologists, and 23 midlevel providers. Most groups improved in identifying the finding type (P < 0.05). All occupations showed improved use of descriptive terms for the shape and internal echogenicity of masses (P < 0.05). Most groups showed significant improvement in recommendations for normal and benign findings with a corresponding reduction in biopsy recommendations., Conclusions: Targeted breast ultrasound education using a condensed BI-RADS improved the interpretive performance of healthcare workers and was particularly successful in reducing the frequency of unnecessary biopsies for normal and benign findings. Multimodal educational efforts to improve accuracy and management of breast ultrasound findings may augment breast cancer early detection efforts in resource-limited settings., (Copyright © 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of our study was to evaluate the performance of DWI to detect mammographically occult breast cancer in elevated-risk women with dense breasts., Materials and Methods: We retrospectively reviewed all women who underwent screening breast MRI at our institution from January 2007 through May 2013. We created a case-control cohort composed of 48 subjects with mammographically dense breasts: 24 with mammographically occult cancer detected on MRI and 24 healthy women with negative MRI findings who were matched to the subjects with breast cancer patients for age, breast density, and MRI protocol. The contrast-to-noise ratio (CNR), apparent diffusion coefficient (ADC), and conspicuity score (range, 1-5) were assessed on DWI for all malignancies. Lesions and normal tissue were compared using the Wilcoxon signed rank test; associations with clinical characteristics were evaluated using the Mann-Whitney U test. Three experienced breast imagers who were blinded to medical records and contrast-enhanced MRI findings independently evaluated the unenhanced MRI scans of the 48 women for the presence of cancer., Results: Mammographically occult breast cancers (invasive carcinoma, n = 16; ductal carcinoma in situ, n = 8) in women with dense breasts typically exhibited higher signal intensity on DWI than normal parenchyma (median CNR of cancers, 1.4; median conspicuity score of cancers, 4) and a lower ADC (median, 1.31 vs 1.79 × 10(-3) mm(2)/s, respectively) (p < 0.0001). The conspicuity score, CNR, and ADC were not associated with patient age, menopausal status, lesion size, morphologic type, or histology (p > 0.05). Average reader performance using unenhanced MRI was 45% sensitivity, 91% specificity, 62% positive predictive value, and 83% negative predictive value., Conclusion: In elevated-risk women with dense breasts, DWI can reveal cancers in addition to those detected on mammography alone with a low false-positive rate; these results suggest that DWI may have potential as a rapid supplemental screening tool.

Objective: To determine whether a semiautomated voxel selection technique improves interreader reproducibility for breast apparent diffusion coefficient (ADC) measurements., Methods: Three readers retrospectively performed ADC measurements of 31 breast lesions (16 malignant, 15 benign) and contralateral normal tissue in 26 women both unassisted (manual method) and assisted by a semiautomated software tool that excludes voxels below a dynamically specified signal intensity threshold. Reproducibility between readers for each technique was assessed by Bland-Altman analysis and concordance correlation coefficients (CCCs)., Results: Differences between readers' measured ADCs of lesions were smaller with the semiautomated tool vs the manual method. Concordance correlation coefficients for each reader pair were greater with the semiautomated tool for lesions (mean CCC difference, 0.11; 95% confidence interval, 0.04-0.26). For normal tissue, reader agreement was lower than for lesions and did not differ based on software tools (mean CCC difference, 0.00; 95% confidence interval, -0.14 to 0.13)., Conclusions: A semiautomated voxel selection tool can improve interreader reproducibility of breast lesion ADC measures.

Despite increases in mammography rates among Latinas, screening rates remain lower than in non-Latina Whites and Latinas typically present with breast cancer at a later stage. Trained lay community workers (promotores) have been successfully used to increase screening mammography intention in Latinas. Little is known, however, about the potential mechanisms of these interventions, such as increased breast cancer knowledge (knowledge) and social interactions concerning mammography practices (social engagement). This prospective pre-post study examined this gap in the literature by (1) documenting changes in knowledge and social engagement after receipt of a promotores-based intervention; and (2) establishing if post-intervention knowledge and social engagement predicted mammography intention, after adjusting for socio-demographic and lifetime mammography history. There were significant increases in knowledge and social engagement about mammography. Finally, post-intervention social engagement was a significant predictor of mammography intention. Future promotores-based interventions should focus on enhancing social engagement to improve mammography intention and use.

Purpose: To investigate whether qualitative magnetic resonance (MR) imaging assessments of background parenchymal enhancement (BPE), amount of fibroglandular tissue (FGT), and mammographic density are associated with risk of developing breast cancer in women who are at high risk., Materials and Methods: In this institutional review board-approved HIPAA-compliant retrospective study, all screening breast MR images obtained from January 2006 to December 2011 in women aged 18 years or older and at high risk for but without a history of breast cancer were identified. Women in whom breast cancer was diagnosed after index MR imaging comprised the cancer cohort, and one-to-one matching (age and BRCA status) of each woman with breast cancer to a control subject was performed by using MR images obtained in women who did not develop breast cancer with follow-up time maximized. Amount of BPE, BPE pattern (peripheral vs central), amount of FGT at MR imaging, and mammographic density were assessed on index images. Imaging features were compared between cancer and control cohorts by using conditional logistic regression., Results: Twenty-three women at high risk (mean age, 47 years ± 10 [standard deviation]; six women had BRCA mutations) with no history of breast cancer underwent screening breast MR imaging; in these women, a diagnosis of breast cancer (invasive, n = 12; in situ, n = 11) was made during the follow-up interval. Women with mild, moderate, or marked BPE were nine times more likely to receive a diagnosis of breast cancer during the follow-up interval than were those with minimal BPE (P = .007; odds ratio = 9.0; 95% confidence interval: 1.1, 71.0). BPE pattern, MR imaging amount of FGT, and mammographic density were not significantly different between the cohorts (P = .5, P = .5, and P = .4, respectively)., Conclusion: Greater BPE was associated with a higher probability of developing breast cancer in women at high risk for cancer and warrants further study., ((©) RSNA, 2015 Online supplemental material is available for this article.)

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