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To retrospectively review nonspecific findings on prior screening mammograms to determine what features were most often deemed normal or benign despite the development of breast cancer in the same location detected at follow-up screening.Four hundred ninety-three pairs of consecutive mammographic findings were collected from 13 institutions, consisting of initial normal screening findings and a subsequent finding of cancer at screening (mean interval between examinations, 14.6 months). One designated radiologist reviewed each pair of mammograms and determined that 286 findings were judged visible at prior examination in locations where cancer later developed. Five blinded radiologists independently reviewed the prior findings in these 286 cases, identifying 169 mammograms (172 cancers) with findings so subtle that none or only one or two of the five radiologists recommended screening recall. Two unblinded radiologists reviewed the initial and subsequent findings and recorded descriptors and assessments for each finding and subjective factors influencing why, although the lesion was perceptible, it might have been undetected or not recalled.Of 172 cancers, 129 (75%) were invasive (112 T1 tumors and 17 T2 tumors or higher; median diameter, 10 mm), and 43 (25%) were ductal carcinoma in situ (median size, 10 mm). On the prior mammograms, 80% (137 of 172) of these cancers had subtle nonspecific findings where cancer later developed, and most were assessed as being normal or benign in appearance.There is a subset of cancers that display perceptible but nonspecific mammographic findings that do not warrant recall, as judged by both a majority of blinded radiologists and by unblinded reviewers. We believe failure to act on these nonspecific findings prospectively does not necessarily constitute interpretation below a reasonable standard of care.

Rationale and Objectives Although research has successfully documented variability in radiologists' interpretation of mammograms, it has failed to determine the relative contributions of case-specific features and reader inconsistency. Training interventions to improve consistency will be ineffectual if they do not target the principal determinants of disagreement among radiologists. The current study assessed the relative contributions of the case and the interpreter to the problem of inconsistent interpretation. Materials and Methods One hundred ten radiologists independently interpreted mammograms from the same 148 screening cases (43% with biopsy-proved cancers) and reported the presence or absence of calcifications, mass, architectural distortion, and asymmetric density in each of 296 breasts. The radiologists were blinded to disease status (established at biopsy or follow-up). Results Case-related differences accounted for a greater proportion of interpretation disagreement than did differences between interpreters. The presence of cancer was associated with increased disagreement, perhaps because of the multiplicity of findings. Patient age was also associated with increased disagreement in the reporting of calcifications. Conclusion For screening mammography, increased consistency between radiologists in their recognition and reporting of clinically important findings will best be achieved by reducing disagreement in difficult cases. Current training in the United States addresses difficult cases only as they have been defined intuitively or experientially. The authors' population-based method provides an objective metric to measure case difficulty and basis from which to identify difficult cases for targeted training.

To evaluate performance parameters for radiologists in a practice of breast imaging specialists and general diagnostic radiologists who interpret a large series of consecutive screening and diagnostic mammographic studies.Data (ie, patient age; family history of breast cancer; availability of previous mammograms for comparison; and abnormal interpretation, cancer detection, and stage 0-I cancer detection rates) were derived from review of mammographic studies obtained from January 1997 through August 2001. The breast imaging specialists have substantially more initial training in mammography and at least six times more continuing education in mammography, and they interpret 10 times more mammographic studies per year than the general radiologists. Differences between specialist and general radiologist performances at both screening and diagnostic examinations were assessed for significance by using Student t and chi(2) tests.The study involved 47,798 screening and 13,286 diagnostic mammographic examinations. Abnormal interpretation rates for screening mammography (ie, recall rate) were 4.9% for specialists and 7.1% for generalists (P.001); and for diagnostic mammography (ie, recommended biopsy rate), 15.8% and 9.9%, respectively (P.001). Cancer detection rates at screening mammography were 6.0 cancer cases per 1,000 examinations for specialists and 3.4 per 1,000 for generalists (P =.007); and at diagnostic mammography, 59.0 per 1,000 and 36.6 per 1,000, respectively (P.001). Stage 0-I cancer detection rates at screening mammography were 5.3 cancer cases per 1,000 examinations for specialists and 3.0 per 1,000 for generalists (P =.012); and at diagnostic mammography, 43.9 per 1,000 and 27.0 per 1,000, respectively (P.001).Specialist radiologists detect more cancers and more early-stage cancers, recommend more biopsies, and have lower recall rates than general radiologists.

The objective of this study was to use mathematic models to aid mammography practices in interpreting outcomes data derived from a combination of screening and diagnostic examinations, and in interpreting diagnostic mammography outcomes data that are not segregated by indication for examination.We analyzed outcomes from 51,805 consecutive mammography examinations. Screening and diagnostic examinations were audited separately. Diagnostic examinations were audited by indication for examination. Extrapolating from our known mix of screening (79%) and diagnostic (21%) examinations, we determined expected combined outcomes for various mixes that might be encountered in clinical practice. Similarly, we determined the expected overall diagnostic mammography outcomes for various clinically relevant mixes of indications for examination.Outcomes vary substantially depending on the mix of screening and diagnostic examinations performed. For example, expected outcomes for practices with screening-diagnostic mixes of 90-10% and 50-50% are, respectively: rate of abnormal findings, 6% versus 11%; rate of positive biopsy findings, 38% versus 42%; cancer detection rate, 10 per 1,000 versus 30 per 1,000; mean invasive cancer size, 14.4 mm versus 16.0 mm; nodal metastasis rate, 8% versus 11%; and rate of stage 0 and stage I cancers, 87% versus 82%. Diagnostic outcomes also vary substantially according to indication for examination, with a higher rate of abnormal findings, a higher rate of positive biopsy findings, and a larger mean invasive cancer size expected for mixes involving a high percentage of workups for palpable lesions.When screening and diagnostic mammography outcomes are not segregated during auditing, and when diagnostic outcomes are not segregated by indication for examination, analysis of combined audit data should be based on extrapolations from known outcomes.

To examine how frequently Breast Imaging Reporting and Data System (BI-RADS) mammographic screening assessments were associated with expected clinical management recommendations.Seven Breast Cancer Surveillance Consortium mammography registries recorded screening assessments and recommendations in 1997 to identify the proportion of women in each BI-RADS category. The first screening assessment for a woman without cancer or a prior mammogram within 9 months was associated with its independently recorded recommendation.Among 292,795 women, screening assessments included 269,022 (91.9%) with a "negative" or "benign finding," and 267,103 (99.3%) of these women were recommended for normal interval follow-up. Among 11,861 (4.1%) women with screening assessments of "probably benign finding," 4,782 (40.3%) were recommended for short interval follow-up as expected on the basis of the BI-RADS, but a high proportion (36.9%) were recommended for additional imaging. Among 1,625 (0.6%) women with "suspicious abnormality," most were recommended for biopsy (48.7%) or clinical examination and/or surgical consult (9.0%), but many were recommended for additional imaging (38.7%). Among 243 (0.1%) women with screening assessments "highly suggestive of malignancy," a majority were recommended for biopsy (73.3%) or clinical examination and/or surgical consult (18.1%) consistent with BI-RADS, but some were recommended for additional imaging (6.6%).BI-RADS assessments and management recommendations are consistent for negative and benign assessments, but inconsistencies were found in assessments and recommendations for mammographic abnormalities.

To examine whether mammographic assessments and recommendations are linked as expected, based on the Breast Imaging Reporting and Data System (BI-RADS), for the evaluation of women with signs and symptoms of breast disease.Eight mammography registries from the Breast Cancer Surveillance Consortium contributed mammographic data from 1996 through 1997 for women 25 years of age or older, with signs or symptoms of breast cancer. The association of assessments and recommendations and the relationship of self-reported symptoms to assessments are described.A total of 51,673 diagnostic mammograms were included in the analyses and the expected management recommendation was provided 85%-90% of the time for mammograms classified as assessment categories 1, 2, 4, or 5. Category 3 ("probably benign finding") had the most variability in associated management recommendations, with only 40% (2,998 of 7,423) of cases associated with the recommendation for short interval follow-up. Of the 1,648 category 0 mammograms ("needs additional imaging") that did not have a final assessment, 64% were recommended for additional imaging, while another 20% of the cases were recommended for either a consultation or biopsy. The number of women who reported a lump as a symptom decreased with age but was associated with higher BI-RADS assessments.BI-RADS assessment categories were generally used as intended for all categories but 0 and 3. Additional education about the use of these categories may be warranted. The inconsistencies between assessment category and management recommendations may present difficulties in conducting outcome audits.

Our study contributes important information to existing literature in that we identified six performance cut points important for interpretation of screening mammograms and found that most of the cut points we identified would affect between 20% and 49% of interpreting physicians, who might benefit from additional training to improve their mammogram interpretation skills.

This paper discusses our initial efforts to design and develop a digital mammography data warehouse to facilitate clinical and research activities. Data warehouse is a complete and consistent integration of data from many information sources. It enables users to explore the warehouse for various analysis and decision support purposes. We are designing an infra-structural information system by incorporating various kinds of breast imaging data, from a diversity of existing clinical systems, into a digital data warehouse. Various types of breast imaging data, including patient demographics, family history, digital mammography and radiological reports, will be acquired for the University of California San Francisco digital mammography PACS modules, as well as Radiological Information System.

To retrospectively determine the mammographic characteristics of cancers missed at screening mammography and assess the ability of computer-aided detection (CAD) to mark the missed cancers.A multicenter retrospective study accrued 1,083 consecutive cases of breast cancer detected at screening mammography. Prior mammograms were available in 427 cases. Of these, 286 had lesions visible in retrospect. The 286 cases underwent blinded review by panels of radiologists; a majority recommended recall for 112 cases. Two experienced radiologists compared prior mammograms in 110 of these cases with the subsequent screening mammograms (when cancer was detected), noting mammographic characteristics of breast density, lesion type, size, morphology, and subjective reasons for possible miss. The prior mammograms were then analyzed with a CAD program.There were 110 patients with 115 cancers. On the prior mammograms with missed cancers, 35 (30%) of the 115 lesions were calcifications, with 17 of 35 (49%) clustered or pleomorphic. Eighty of the 115 (70%) were mass lesions, with 32 of 80 (40%) spiculated or irregular. For calcifications and masses, the most frequently suggested reasons for possible miss were dense breasts (12 of 35; 34%) and distracting lesions (35 of 80; 44%), respectively. CAD marked 30 (86%) of 35 missed calcifications and 58 (73%) of 80 missed masses.Detection errors affected cases with calcifications and masses. CAD marked most (77%; 88 of 115) cancers missed at screening mammography that radiologists retrospectively judged to merit recall.

There is now solid scientific evidence, derived from several randomized controlled trials, of a statistically significant breast cancer mortality reduction for women age 40 and older who undergo routine screening mammography. 2,6,21 Because of the convincing nature of this evidence, the remaining controversy about the widespread use of screening has, for the most part, shifted to concerns about the risks (harms) of mammography, concentrating on the morbidity and economic costs of false-positive cases. 3,13,14 It is beyond the scope of this article to join in the debate. Rather, the aim herein is to discuss several already demonstrated methods that permit radiologists safely and effectively to reduce the frequency of false-positive mammography interpretations. In my opinion, the widespread implementation of these successful methods currently represents the best argument in defense of mammography that can be advanced by the radiology community. One must remember that the primary goal of mammography is to detect nonpalpable, favorable-prognosis cancer; it is not to have relatively few false-positive cases. As a first priority, the radiologist should strive to achieve a high cancer detection rate, with the great majority of cancers being nonpalpable and early in stage. Only once such a level of success is demonstrated should one attempt to reduce the rate of false-positive interpretations. In other words, first establish the benefit and then attempt to minimize the harms (while maintaining an acceptable level of benefit). Because any strategy designed to reduce the frequency of false-positive cases requires examinations otherwise interpreted as positive to instead be read as negative, and because this leads to a reduction in the number of true-positive cases if any cancers are thereby overlooked, it is clear that successful approaches to reducing false-positive interpretations achieve this goal only if there is no more than a minor decrease in the early detection of favorable-prognosis cancers. Any initially overlooked cancers should still be of good prognosis when ultimately detected, demonstrating favorable clinical outcomes after treatment.

To practice mammography diagnosis effectively, radiologists expect convenient access to well-organized and authoritative mammography related information, especially when there is case in question. The purpose of this study is to build infrastructural diagnosis support by incorporating various clinical information into a digital mammography case library, and allow user to search the library based on mammographic findings. The digital mammography case library has a three- tier architecture: (1) Back-end mammography databases integrate multimedia clinical information from various operational systems, including RIS and PACS. Cases are stored in a finding index database powered by an object-relational database with finding-coded reports, which are modeled around the ACR BI-RADS (American College of Radiology, Breast Imaging Report and Data System) standard. (2) The middle-end application controllers process application logic, such as user authorization, HTTP request handling, database connection and dynamic HTML page generation. (3) Web-based user interface is developed for authorized Intranet personnel to formulate query based on radiological finding (such as mass, calcification and architectural distortion), shape and assessment, using ACR BI-RADS specified lexicon. The case library so far has 103 cases selected from over 800 digital mammography studies carried out at the Mt. Zion hospital, UCSF, during an on-going digital telemammography project. We believe that an Intranet based digital mammography case library with mammographic finding search capability facilitates continuous medical education and online decision support, by providing exemplary study to compare with case in question.

The purpose of this project is to study the feasibility of remotely managing mammography examinations in real time. To do so, the remotely located expert mammo-grapher needs to view newly generated images and communicate with on-site technologist before a patient leaves the examination room. A telemammography test-bed has been setup between two UC San Francisco clinical facilities. In the current system, the overhead of network and disk I/O delays the image availability at the remote expert workstation. We modified the communication software to enable memory-to-memory image transfer. Besides, we optimized the data flow between the hosts to enable images be directly transmitted from the digital mammography console to the remote display workstation. In this paper, we present the implementation of fast telemanagement in digital mammography environments. The preliminary results show the feasibility of adding telemanagement protocol into the current telemammography system.© (2000) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

We determined differences in the rates of recall, biopsy, and cancer detection for screening mammography as a function of adiposity.Eighty-eight thousand three hundred forty-six consecutive screening mammography examinations were performed from April 1985 to August 1997. Patient weights were normalized to ideal weight correcting for height and were subdivided into adiposity cohorts including underweight by greater than 10%; ideal weight +/- 10%; overweight by 11-24%; overweight by 25-39%; and overweight by greater than 40%. The rates of recall, biopsy, cancer detection, and cancer stage were calculated and were analyzed using the chi-square test for trend. Cancer size was analyzed using linear regression analysis.Reliable (p0.05) and meaningful differences were seen between cohorts of increasing adiposity for rates of recall, biopsy, and cancer detection. An increase in recall rate occurred with progressively increasing adiposity (3.88%, 4.89%, 5.11%, 5.47%, 5.55% [p0.0001]). The rate of biopsy also increased with increasing adiposity (0.98%, 1.31%, 1.35%, 1.59%, 1.65% [p0.0002]), as did the rate of screening-detected cancer (number of cases of cancer per 1000 women screened) (3.74, 4.29, 5.34, 4.70, 6.04 [p0.015]). Finally, increased adiposity also correlated with increased median cancer size (p0.02) and with more advanced stage at diagnosis (p = 0.046).Increasing adiposity correlates with progressive increases in the rates of recall, biopsy, and cancer detection for women undergoing screening mammography. Increasing adiposity also correlates with increased cancer size and stage, providing further support for obesity as a risk factor for breast cancer.

Broeders: Breast Cancer Epidemiology and Risk Factors Tulusan: Mammographic-Pathologic Correlations Haus: Technical Aspects of Screen-Film Mammography Hendrick: Current Legislation on Mammography Quality Assurance Oestmann: Digital Mammography Eklund: The Art of Mammographic Positioning Lanyi: Differential Diagnosis of Microcalcifications Adler: Imaging Evaluation of Spiculated Masses Pisano: The Management of Nonpalpable Circumscribed Breast Masses Stickles: Management of Lesions Appearing Probably Benign at Mammography Feig et al: Radiation Risk of Mammography Teubner: Breast Ultrasonography:Technique and Results Delorme: Doppler Sonography of Breast Tumors Friedrich: Magnetic Resonance Imaging of the Breast Junkermann et al: Prebiopsy Localization of Nonpalpable Breast Lesions Bauer et al: Fine Needle Aspiration and Core Biopsy Mendelson: Imaging the Breast After Radiation and Surgery De Bruhl: Imaging after Breast Implants Schreer et al: Breast Cancer Screening Projects: Results Warren Burhenne: Breast Cancer Screening: General Guidelines Program Design and Organization Brenner: Medicolegal Aspects of Breast Imaging.

This research investigates an important application of full-field direct digital mammography (FFDDM): telemammography, the electronic transfer of digital mammography images to remote viewing sites. This should permit radiologists with great interpretive expertise to manage and read in real time all mammography examinations in a multiple-site practice, an approach that is theoretically superior to either deferred interpretation by expert readers or real-time interpretation by general radiologists. We have acquired a large data set of FFDDM cases, demonstrated that the time involved in data transmission and off-site image interpretation is shorter than the corresponding time for on-site image processing and interpretation of conventional film mammograms, and shown that remote interpretation of FFDDM images by expert mammographers is somewhat more effective than conventional film interpretation by general diagnostic radiologists (statistical significance demonstrated, but follow-up of non-biopsied cases not yet sufficiently long to reach a firm conclusion). By showing that telemammography technology can be developed for routine clinical operation, and that real-time off-site management and interpretation of a general-radiologist mammography practice by mammography specialists is feasible as standard operating procedure, we expect to establish telemammography applications of digital radiography as both valid and useful. The application of these procedures to routine mammographic examinations should bring to bear the expertise of mammography specialists at the community-practice general-radiologist level. This should benefit all women undergoing mammography in the future.

PURPOSE: The staging and treatment for breast cancer are changing; there is an increase in the incidence of ductal carcinoma-in-situ, the use of fine-needle aspiration and stereotactic biopsy for diagnosis, and the use of neoadjuvant chemotherapy. Thus, there is a need for a tool to assess more precisely the extent of cancer in the breast before surgery. To better plan surgical and chemotherapeutic interventions, we evaluated high-resolution magnetic resonance imaging (MRI) as such a tool. PATIENTS AND METHODS: Fifty-seven patients with 58 cases of breast cancer were evaluated preoperatively with MRI using a technique called the triple-acquisition rapid gradient echo technique to maximize anatomic detail. Imaging results were compared with mammography and subsequent pathology results. RESULTS: Magnetic resonance imaging correctly identified residual or primary cancer in 55 of 58 cases and accurately predicted the extent of the cancer in 54 of 58 cases. The anatomic extent was more accurately defined with MRI compared with mammography (98% v 55%). Magnetic resonance imaging added the greatest value in cases of multifocal disease. CONCLUSION: By applying MRI selectively to patients with a known diagnosis of cancer and focusing on defining the extent of malignant lesions, we were able to obtain clear and accurate anatomic information. Our results suggest that MRI could provide very valuable information for preoperative planning and single-stage resection in breast cancer. Based on preliminary data from our series, MRI would be valuable as a staging tool in the preoperative setting even if the cost is in the range of $1,300 to $2,000. It is already significantly less than the target cost, so it is reasonable to refine this technique for clinical use to help plan the most appropriate surgical intervention and possibly reduce costs as well. A careful prospective study is warranted to validate our findings.

The purpose of this project is to investigate the feasibility to remotely manage mammography examinations in real time, which is defined as mammography telemanagement. In such a scenario, the remotely located expert mammographer needs to view newly generated images and communicate with on-site technologist before a patient leaves the exam room. Therefore, almost real-time transmission of large volume digital mammograms between these two parties must be available. A digital telemammography test-bed has been setup between two clinical facilities in University of California, San Francisco. Both the hardware and software components of the system are discussed. Digital mammogram transmission between two campuses, however, is not yet optimal. Several methods are presented to improve the image availability. By implementing these schemes, the total time for transferring one digital mammogram from the FFDM to the remote expert workstation is reduced form 42 sec to 6 sec. It is concluded that, with improved system design and extended software capabilities, it is feasible to explore real-time telemanagement protocol in telemammography.© (1999) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Background: Several studies, which were limited by their small sample size and selection of difficult cases for review, have reported substantial variability among radiologists in interpretation of mammographic examinations. We have determined, in the largest study to date, intraobserver and interobserver agreement in interpreting screening mammography and accuracy of mammography by use of the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS). Methods: The mammographic examinations were randomly selected on the basis of original mammographic interpretation and cancer outcome from 71 713 screening examinations performed by the Mobile Mammography Screening Program of the University of California, San Francisco, during the period from April 1985 through February 1995. The final sample included 786 abnormal examinations with no cancer detected, 267 abnormal examinations with cancer detected, and 1563 normal examinations. Films were read separately by two radiologists according to BI-RADS. Cancer status was determined by contacting women’s physicians and by linkage to the regional Surveillance, Epidemiology, and End Results Program. Results: There was moderate agreement between radiologists in reporting the presence of a finding when cancer was present (k = 0.54) and substantial agreement when cancer was not present (k = 0.62). Agreement was moderate in assigning one of the five assessment categories but was statistically significantly lower when cancer was present relative to when cancer was not present (k = 0.46 versus 0.56; two-sided P = .02). Agreement for reporting the presence of a finding and mammographic assessment was twofold more likely for examinations with less dense breasts. Agreement was higher on repeat readings by the same radiologists than between radiologists. The sensitivity of mammography was lower with BI-RADS than with the original system for mammographic interpretation, but the positive predictive value of mammography was higher. Conclusion: Considerable variability in interpretation of mammographic examinations exists; this variability and the accuracy of mammography are neither improved nor diminished with use of BI-RADS. [J Natl Cancer Inst 1998;90: 1801‐9]

Conventional film mammography has several technical limitations which reduce its effectiveness, most of which can be overcome by full-field direct digital mammography (FFDDM). This research investigates an important application of digital breast imaging: telemammography, the electronic transfer of digital mammography images to remote viewing sites. This should permit radiologists with great interpretive expertise to manage and read in real-time all mammography examinations in a multiple-site practice, an approach superior to either deferred interpretation by expert readers or real-time interpretation by general radiologists. During Year 1 of this project, we installed the first of two FFDDM imagers and developed the infrastructure of a telemammography chain between two distant sites. By showing that telemammography technology can be developed for routine clinical operation, and that real-time off-site management and interpretation of a general-radiologist mammography practice by mammography specialists is feasible as standard operating procedure, we expect to establish telemammography applications of digital radiography as both valid and useful. The application of these procedures to routine mammographic examinations should bring to bear the expertise of mammography specialists at the community-practice general-radiologist level. This should benefit all women undergoing mammography in the future.

We are in the process of conducting a research of full-field direct digital telemammography using three protocols: telediagnosis, teleconsultation, and telemanagement. To conduct this research project, an asynchronous transfer mode network based telemammography system was developed across two remote campuses in our facility. The hardware and software components of this system are detailed. The system was embedded in a clinical environment for a four-month test. Some preliminary study results from the current phase of this study are reported.

The digital breast imaging teaching file developed during the last two years in our laboratory has been used successfully at UCSF (University of California, San Francisco) as a routine teaching tool for training radiology residents and fellows in mammography. Building on this success, we have ported the teaching file from an old Pixar imaging/Sun SPARC 470 display system to our newly designed telemammography display workstation (Ultra SPARC 2 platform with two DOME Md5/SBX display boards). The old Pixar/Sun 470 system, although adequate for fast and high-resolution image display, is 4- year-old technology, expensive to maintain and difficult to upgrade. The new display workstation is more cost-effective and is also compatible with the digital image format from a full-field direct digital mammography system. The digital teaching file is built on a sophisticated computer-aided instruction (CAI) model, which simulates the management sequences used in imaging interpretation and work-up. Each user can be prompted to respond by making his/her own observations, assessments, and work-up decisions as well as the marking of image abnormalities. This effectively replaces the traditional 'show-and-tell' teaching file experience with an interactive, response-driven type of instruction.© (1998) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Because of inefficient utilization of current mammography teaching facilities and existing deficiencies in training resources for radiologists, there is a need to supplement or replace the traditional film-based method of training. The purpose of this research is to develop a digital breast imaging teaching file (DBITF) as an interactive training tool for learning and continuing education for radiologists. Two hypotheses are being investigated: (1) a comprehensive DBITF can be designed and implemented using current technology, and (2) this DBITF's interactive response-driven type of instruction is more effective than the traditional "show and tell" type of instruction used with film-based teaching files. To test these hypotheses, our current film-based breast imaging teaching file, which contains over 1,000 pathologically proved state-of-the-art imaging cases, has been converted to digital format. Current technologies in high resolution film digitization, high resolution soft-copy image display, relational database architecture, and computer-aided instruction models have been used to create a DBITF containing these cases. The effectiveness of using the DBITF to teach breast imaging interpretation will be compared with traditional passive film-based teaching. As a result of this research, we expect to develop a comprehensive DBITF as a national resource, which should be superior to other methods of teaching.

Full-field direct digital mammography has many advantages over the conventional film/screen imaging detector. Among these are larger dynamic range, lower scattering noise, and the possibility of using it for telemammography applications to alleviate the shortage of expert mammographers. We are in the process of developing a full-field direct digital telemammography imaging chain to investigate its usefulness for telediagnosis, teleconsultation, and telemanagement. This paper describes the first phase of a three-year research program to set up a full-field direct digital mammography (FFDDM) imaging chain at the Breast Imaging Section connecting the University of California, San Francisco Medical Center and the Mt. Zion Hospital in the San Francisco Bay area. The chain consists of two FFDDM system, and two 2,500 line two-monitor workstations. An OC-3 155 Mbits/sec asynchronous transfer mode (ATM) communication network is used to connect the FFDDM and the two workstations. The FFDDM is based on a slot scan CCD detector which can image a full breast with 3,100 X 3,870 pixels, and produce a direct digital image with 50 micron pixel size. Preliminary results of the FFDDM demonstrate that it has a greater dynamic range and lower detector noise than that of a film-screen detector, and that the scattered radiation is reduced without using a grid. However, the spatial resolution is less than that of the conventional screen/film system. The 2K workstation can display simultaneously any two or four full-view mammographic images by either scrolling or subsampling on the two monitors. Display of an image takes about 1.5 seconds from the RAID disks. The ATM can transmit a 32 Mbyte digital mammogram from the FFDDM to the workstation in 3-4 seconds.

The several randomized controlled trials (RCTs) of breast cancer screening among women of ages 40 to 49 now collectively show a statistically significant reduction in breast cancer mortality. However, there have been numerous recent advances in mammography, such that it now is demonstrably better than when the RCTs were conducted. The use of surrogate measures of screening efficacy (tumor size, lymph node status, cancer stage), readily derived from modern service screening programs, demonstrates how the improved mammography of the 1990s should produce a greater degree of mortality reduction among women ages 40-49 than that already demonstrated in the RCTs. Indeed, these surrogate measures of mortality reduction are as favorable for women of ages 40-49 and 65+ as they are for women of ages 50-64, strongly suggesting that, since modern service screening is accepted as effectively reducing mortality among women of ages 50-64, it should also effectively reduce mortality among women in the 40-49 and 65+ age groups.

Purpose: To describe the impact of California Breast Density Notification law (SB 1538) on policy development, policy implementation and supplemental screening strategies within California medical facilities. SB 1538 mandates that breast density information be given to patients but provides no funding for supplemental screening, no guidance on how to triage women for supplemental screening nor which imaging modalities to use. Methods: As a result of the law, the California Breast Density Information Group (CBDIG) formed from academic and private practice radiologists and risk assessment experts, reviewing scientific literature and nationally recognized guidelines to provide evidence-based recommendations regarding supplemental screening in women with dense breast tissue. A survey was sent to 6 academic and 3 large private practices in California to record their experience in implementing the law. Results: CBDIG created a public, institution-neutral, evidence-based website, “breastdensity.info”, that includes information and recommendations regarding supplemental breast screening, with triage for supplemental MRI or US based on breast cancer risk assessment using genetic or family history risk models. CBDIG facilities worked with referring health care providers to inform them of the new law, educated their staff and technologists on implementing policy, and developed notification strategies to comply with legislation. The survey showed that all 9 facilities recommended supplemental screening based on family history models or genetic testing. 3/9 calculated breast cancer risk in the breast imaging clinic, and 2/9 emailed a risk survey to the patient. 3/9 reported risk in the radiology report, and 1/9 reported risk only if the patient was high risk. Risk assessments were performed by technologists and risk assessment health practitioners. 8/9 facilities estimated breast density by visual methods, and 1/9 by computer. All facilities performed screening breast MRI, 4/9 performed handheld screening US, and 2/9 tomosynthesis. 1/9 obtained tomosynthesis in anticipation of the law, 2/9 are trying to obtain automated whole breast US, and 3/9 are trying to obtain tomosynthesis. Facilities expressed concerns about additional false-positive biopsies produced by supplemental screenings, out-of-pocket expenses for women, and disparities (low income) in notified populations. Conclusion: SB 1538 resulted in the formation of the CBDIG and the website, “breastdensity.info”. Our survey showed variations in imaging modalities available and policy implementation at each facility. Given that several states currently have breast density laws or have laws that will become effective in the near future, it is important for breast imagers and clinicians to be informed of the current literature, realize the variation in equipment and policies at various facilities, and develop recommendation strategies to guide patients seeking supplemental screening. We plan to follow up this survey with a larger survey of the Society of Breast Imagers at a later date. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-01-01.

The education committees of the ACR Commission on Breast Imaging and the Society of Breast Imaging have revised the resident and fellowship training curriculum to reflect the current state of breast imaging in the United States. The original curriculum, created by the Society of Breast Imaging in 2000, had been updated only once before, in 2006. Since that time, a number of significant changes have occurred in the way mammography is acquired, how adjunctive breast imaging methods are used, and how pathology is assessed. This curricular update is meant to reflect these and other changes and to offer guidance to educators and trainees in preparing those interested in providing breast imaging services.

To report the findings a 6-year clinical application of ET on patients with orofacial pain.ET was conducted (in a blinded manner) using an Agema 870 unit at 0.1 degree C thermal accuracy. A newly devised thermal classification system was applied: 'normal' when zone delta T was from 0.0 to +/-0.25 degree C, "hot' when zone delta T was+0.35 degree C, 'cold' when zone delta T was-0.35 degree C, and 'equivocal' when zone delta T was +/-(0.26-0.35) degree C. Study populations consisted of 164 dental patients mainly with diagnostic problems and 164 matched (control) subjects.Our prospective, matched study determined that subjects with 'hot' thermograms had the clinical diagnoses of sympathetically maintained pain, peripheral nerve mediated pain, TMJ arthropathy, and maxillary sinusitis. Subjects with 'cold' thermograms were found to have the clinical diagnoses of peripheral nerve-mediated pain and sympathetically independent pain. Subjects with 'normal' thermograms were found to have the clinical diagnosis of cracked tooth syndrome, trigeminal neuralgia, pretrigeminal neuralgia, or psychogenic facial pain. The new system of thermal classification resulted in 92% (301 of 328) agreement in classification of pain patients and matched controls.These studies suggest that ET has promise in aiding the formation of a differential diagnosis of orofacial pain and may help in understanding mechanisms of pain as well as directing therapies.

Objective. —To determine the sensitivity, specificity, and likelihood ratios (LRs) for modern screening mammography by decade of age and mammographic interpretation. Design. —Cross-sectional. Setting. —Nine counties in northern California. Participants. —A total of 26 057 women aged 30 years and older who underwent a total of 41 747 first and subsequent screening mammographic examinations at the Mobile Mammography Screening Program of the University of California, San Francisco, from April 1985 to September 1991. Measurements. —Breast cancer risk profile, 2 standard mammographic views per breast, and follow-up of abnormal and normal mammograms by contacting women's physicians and by linkage to the regional Surveillance, Epidemiology, and End Results tumor registry. False-negative examinations were normal examinations that occurred within 13 months of a diagnosis of invasive breast cancer or ductal carcinoma in situ. Results. —The sensitivity of first screening mammography increased with age: 77.3% for ages 30 to 39 years, 86.7% for ages 40 to 49 years, 93.6% for ages 50 to 59 years, 94.1% for ages 60 to 69 years, and 91.2% for ages 70 years and older (P=.04). Specificity was similar for all ages, ranging from 92.6% to 95.2%. Of all abnormal first screening examinations, 92.9% were reported as "additional evaluation needed." The LRs for that category ranged from 5.2 to 8.8 and did not vary with age. Based on the risk of breast cancer before mammography, which increases with age, the risk of breast cancer after mammography associated with these LRs were 0.01 for ages 30 to 39 years, 0.02 for ages 40 to 49 years, 0.05 for ages 50 to 59 years, 0.07 for ages 60 to 69 years, and 0.07 for ages 70 years and older. The LRs for mammography reported as "suspicious for malignancy" ranged from 88 to 144 and did not vary across age groups. These LRs were associated with a risk of breast cancer about 10 times greater than when mammography was reported as "additional evaluation needed." Conclusions. —Most abnormal first screening mammography are interpreted as "additional evaluation needed" and are associated with LRs of about 7. Given this low LR, the risk of breast cancer after mammography is primarily influenced by a woman's age-specific risk of breast cancer before mammography. The LRs for screening mammography interpreted as "suspicious for malignancy" are high (about 124) and are associated with a substantial increase in the risk of breast cancer irrespective of age, but these interpretations comprise only a small proportion of abnormal mammography.

The purpose of this study was to gather from 50 community mammography practices that were included in the National Survey of Mammography Facilities data concerning abnormal findings on screening mammograms to determine the frequency of various recommendations made for patients who had abnormal findings and to compare these recommendations with the frequency with which the procedures were actually performed. We also determined the positive predictive value of screening mammograms (the number of cancers detected per 100 abnormal findings) and the yield (the number of cancers detected per 100 procedures done) of various diagnostic procedures done because of abnormal findings.We identified 1717 screening mammograms done in the last half of 1991 that had abnormal findings. Radiologic recommendations and follow-up procedures, including repeat standard (screening) mammography, additional mammographic views, sonography, clinical breast examination, needle aspiration, needle biopsy, and open biopsy, were identified for all of the cases from the radiologic records, and follow-up data were obtained from referring physicians. The positive predictive value and yield in the National Survey of Mammography Facilities were compared with data from the mammography screening practice of the University of California at San Francisco (UCSF), a facility noted for its clinical efficiency.We estimate that 11% of all screening mammograms resulted in a recommendation for further diagnostic procedures. These 1717 mammograms with abnormal findings led to the following recommendations and procedures: repeat standard (screening) mammography, 610 (recommended)/635 (performed); additional mammographic views, 785/707; sonography, 400/345; biopsy, 189/229; and needle aspiration, 21/51. More procedures were done than were recommended in some cases because the results of certain procedures often led to the performance of other, additional procedures. The positive predictive value for screening examinations with abnormal findings was 3.5%, and the yield for open biopsy was 21%. In the UCSF data base, the positive predictive value for examinations with abnormal findings was 10%, and the yield for open biopsy was 34%.The positive predictive value for examinations with abnormal findings and the yield for diagnostic procedures performed as a result of abnormal findings in 50 community radiologic facilities were higher than those reported in some earlier studies, a fact that raised concern about the induced cost of screening mammography. However, these values were low compared with those in the UCSF data base. This fact was particularly true of repeat standard (screening) mammography.

The goal of this study was to compare findings on initial and subsequent screening mammograms to determine the prognostic significance of screening-detected abnormalities.All 3386 abnormal examinations from a 9-year mammographic screening program were studied. An initial examination was defined as one for which there were no prior films available for comparison (even if one or more prior examinations had been performed); the remainder were called subsequent examinations. The principal mammographic feature of each abnormality was recorded, as well as whether a biopsy was performed. For all screening-detected cancers, we also determined several surrogate markers of prognosis (tumor size, presence of axillary lymph node metastasis, and tumor stage). These various parameters were analyzed as a function of initial versus subsequent screening.The frequency of abnormal examinations was more than 2 times greater for initial examinations (7%) than for subsequent examinations (3%). Only minor differences were noted between initial and subsequent screenings when comparing the principal mammographic features of the abnormalities. However, the number of cancers found per number of biopsies performed was significantly greater (p = .02) for subsequent screenings (41%) than for initial screenings (32%). Among the 333 cancers detected, tumor size was significantly smaller for subsequent screenings (p = .0076). Node-negative status and early tumor stage (stage 0 or 1) also were found more frequently for subsequently screened cancers, but these differences were not statistically significant.Substantially fewer abnormal screening interpretations are made when mammography has been performed previously and when the prior films are available for comparison. This results in cost savings and reduced morbidity at subsequent screening (no further work-up, less patient anxiety, fewer benign biopsies). Surrogate markers of prognosis also appear to be more favorable for cancers detected at subsequent screening.

The purpose of our study was to compare the major prognostic factors (tumor size, axillary lymph node status, and tumor stage) of breast cancers detected at mammographic screening in women ages 40-49 years old with those in women ages 50-64 years old.Study subjects were women ages 40-64 years old who participated in our mobile van mammographic screening program from April 1985 to June 1994. We retrospectively reviewed the clinical and pathology records of women in whom breast cancer was detected at mammographic screening. All examinations were performed with dedicated equipment using screen-film technique.A total of 44,301 screening examinations were done during the study period. Seventy-five cancers were detected in women ages 40-49 years old, and 128 cancers were detected in women ages 50-64 years old. The cancer detection rate was 3.0 per 1000 examinations in the younger age group compared with 5.5 per 1000 examinations in the older age group. The median size of breast cancers was 10 mm for women ages 40-49 versus 11 mm for women ages 50-64. Eighty-eight percent of the patients in both age groups had no evidence of metastasis to axillary lymph nodes. Nineteen percent of women in the younger age group had advanced breast cancer (stage II or higher) compared with 26% of women ages 50-64 (p = .25). No statistically significant differences were noted between the two age groups in the size, lymph node status, or stage of breast cancers detected at mammographic screening. However, the cancers found in younger women had slightly more favorable prognoses.The major prognostic factors of cancers detected with modern mammographic equipment appear to be at least as favorable for women ages 40-49 years old as for women ages 50-64 years old. As mammographic screening has already been shown to be beneficial for women ages 50-64 years old, screening should also be beneficial for women ages 40-49 years old.

The data from population-based, randomized trials of the mammographic screening of women aged 40 to 49 years are limited by retrospective subgroup analysis, low statistical power, and the use of older mammographic techniques. Nonetheless, meta-analysis involving the most recently reported data from all similarly designed trials shows a 21% mortality reduction in women who have had mammographic screening compared with those in control groups, a statistically significant difference (upper bound of 95% Cl, 0.98). Evidence from modern mammography demonstration projects (which are limited by a lack of control groups and the unavailability of mortality results) also shows that the tumor size, axillary lymph node status, and stage of screening-detected breast cancers in women aged 40 to 49 years indicate that screening is at least as beneficial for these women as it is for those aged 50 to 64 years, for whom mammographic screening is widely accepted. Overall, the evidence suggests that screening will benefit women aged 40 to 49 years, but some argue that the level of proof provided is not rigorous enough to establish the efficacy of screening. In the United States, more than 10,000 deaths per year occur among women who develop breast cancer between the ages of 40 and 49. Thousands of lives are probably lost each year because women are not being screened. We believe that it is much more prudent to endorse mammographic screening now, risking the unlikely subsequent determination that the effort was ineffective, than to withhold screening until it is determined whether "proof" of efficacy will be obtained, risking the loss of so many lives. We urge primary care practitioners to recommend routine mammography for women aged 40 to 49 years.

PURPOSE: To assess the clinical relevance of latent image fading due to time delays in batch-processed screening mammograms. MATERIALS AND METHODS: Results of all 66,667 mammographic examinations performed in a mobile van since April 1985 were retrospectively analyzed. Film was routinely batch processed at the end of the workday. The rate of repeat examination due to poor image quality, rate of abnormal interpretation, and rate of cancer detection were studied. RESULTS: Essentially no differences were found in the rates at which repeat examination was necessary, abnormal interpretations were made, or breast cancers were detected when examinations performed at the beginning, middle, and end of the workday were compared (time delays in film processing ranged from 15 minutes to 8 hours). CONCLUSION: Latent image fading is not accompanied by clinically relevant impairment of results if films are processed at the end of the workday. Latent image fading should not deter the use of batch-film processing.

Few studies have examined the comparative effectiveness of digital versus film-screen mammography in U.S. community practice.To determine whether the interpretive performance of digital and film-screen mammography differs.Prospective cohort study.Mammography facilities in the Breast Cancer Surveillance Consortium.329,261 women aged 40 to 79 years underwent 869 286 mammograms (231 034 digital; 638 252 film-screen).Invasive cancer or ductal carcinoma in situ diagnosed within 12 months of a digital or film-screen examination and calculation of mammography sensitivity, specificity, cancer detection rates, and tumor outcomes.Overall, cancer detection rates and tumor characteristics were similar for digital and film-screen mammography, but the sensitivity and specificity of each modality varied by age, tumor characteristics, breast density, and menopausal status. Compared with film-screen mammography, the sensitivity of digital mammography was significantly higher for women aged 60 to 69 years (89.9% vs. 83.0%; P = 0.014) and those with estrogen receptor-negative cancer (78.5% vs. 65.8%; P = 0.016); borderline significantly higher for women aged 40 to 49 years (82.4% vs. 75.6%; P = 0.071), those with extremely dense breasts (83.6% vs. 68.1%; P = 0.051), and pre- or perimenopausal women (87.1% vs. 81.7%; P = 0.057); and borderline significantly lower for women aged 50 to 59 years (80.5% vs. 85.1%; P = 0.097). The specificity of digital and film-screen mammography was similar by decade of age, except for women aged 40 to 49 years (88.0% vs. 89.7%; P0.001).Statistical power for subgroup analyses was limited.Overall, cancer detection with digital or film-screen mammography is similar in U.S. women aged 50 to 79 years undergoing screening mammography. Women aged 40 to 49 years are more likely to have extremely dense breasts and estrogen receptor-negative tumors; if they are offered mammography screening, they may choose to undergo digital mammography to optimize cancer detection.National Cancer Institute.

To determine the positive predictive value (PPV) of low-cost screening mammography according to age and family history of breast cancer.Cross-sectional.Six counties in northern California.A total of 31,814 women aged 30 years and older referred for mammography to the University of California, San Francisco, Mobile Mammography Screening Program from April 18, 1985, through November 20, 1992.Breast cancer risk profile, two standard mammographic views per breast, and follow-up of abnormal screening examinations.Although women aged 50 years or older constituted only 38.3% of all women who received first-screening mammography, 74% of breast cancers were detected in this group. Ten cancers were diagnosed per 1000 first-screening examinations in women aged 50 years or older, with 14.8 diagnostic procedures per cancer diagnosed compared with two cancers per 1000 screening examinations and 48.3 diagnostic tests per cancer diagnosed in women younger than 50 years. The PPV of first-screening mammography (number of breast cancers detected per abnormal examination) increased with age: .03 for those aged 30 to 39 years; .04 for those aged 40 to 49; .09 for those aged 50 to 59; .17 for those aged 60 to 69; and .19 for those aged 70 years or older (chi 2 for trend, P.001). Women aged 50 to 59 years had a higher PPV for first-screening mammography than women aged 40 to 49 years (.09 vs. .04; P = .004), and women with a family history of breast cancer had higher PPVs compared with women without history (40 to 49 years of age, .13 vs .04, P = .01; and 50 to 59 years of age, .22 vs .09, P = .01).Five times as many cancers per 1000 first-screening mammographic examinations were diagnosed in women aged 50 years or older compared with women aged less than 50 years. The highest PPVs for mammography were in women aged 50 years or older and in women aged 40 years or older with a family history of breast cancer. Efforts to promote screening mammography should focus on women in these groups, in whom the majority of breast cancers occur and for whom mammography has the highest PPVs.

To define the role of special mammographic views in evaluating palpable breast masses, 70 consecutive women with palpable breast masses underwent standard two-view examination of each breast and spot compression-magnification and tangential view examination of the palpable mass. Thirty palpable masses were found in 30 patients (43%). Standard views depicted 26 masses (87%). Tangential views also depicted 26 masses. Some of the masses seen on tangential views were not seen on standard views and vice versa. Spot compression-magnification views depicted 29 masses (97%). Special views thus depicted an additional 9% of palpable masses not seen on standard views (four of 44 cases). All lesions not seen on tangential views were central; the one lesion not seen on spot compression-magnification views was peripheral. Special views allowed correct prediction of benign or malignant status in 77% of cases (23 of 30), while standard views allowed correct prediction in 69% of cases (18 of 26).

Mammography is generally accepted as a useful problem-solving clinical tool in characterizing known breast lesions, so that appropriate and timely treatment can be given. However, it remains grossly underutilized at what it does best: screening. The major strengths of mammography are a) its ability to detect breast cancer at a smaller, potentially more curable stage than any other examination, and b) its proved efficacy in reducing breast cancer mortality in asymptomatic women aged 40–74. If, as has recently been estimated, screening with mammography and physical examination can be expected to lower breast cancer deaths by 40%–50% among those actually examined (13), then the lives of almost 20,000 U.S. women might be saved each year if screening were to become very widely used. The challenges of the next decade are clear, to mount much more effective campaigns to educate physicians and lay women about the life-saving benefits of breast cancer screening, to devise increasingly effective and lower cost screening strategies, to further improve the current high quality of mammographic imaging despite its increasing proliferation, and to train large numbers of breast imaging specialists to guarantee that the growing case load of screening and problem-solving mammograms is interpreted with a very high level of skill.

Mammograms from the Canadian National Breast Screening Study (NBSS) were reviewed by three external experts to provide an objective evaluation of their technical quality, to establish a model for auditing mammograms in a screening program, and to assess whether NBSS mammograms improved over time. The sample reviewed included 10 randomly chosen mammograms from each of 15 screening centers for each calendar year of their operation between 1980 and 1987. All 830 mammograms were reviewed on two consecutive days in randomized sequence by each reader, and rated 0-3 for each of four criteria including positioning and image quality, with a total possible score of 0-12. Although the mammograms were not in temporal sequence when reviewed, the scores assigned by each reader were significantly higher for mammograms dating from later years. Subjects' ages at entry (40-49 vs 50-59 years) did not affect the score. The largest increase in scores was associated with a 1985 protocol change in which mediolateral oblique positioning replaced straight mediolateral positioning. This study reinforces the importance of monitoring technical quality in screening programs and establishes that the NBSS benefited from technical improvements during its operation. A retrospective review of NBSS mammography by three external reviewers confirmed that technical quality improved from 1980 to 1987. This improvement was associated with improved technology (film, processing, and units) and with the quality assurance programs operating during the NBSS, which identified problems and offered remedies.