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Objective There is insufficient large-scale evidence for screening mammography in women Methods This retrospective, HIPAA-compliant, institutional review board–exempt study analyzed data from 150 NMD mammography facilities in 31 states. Patients were stratified by 5-year age intervals, availability of prior mammograms, and specific risk factors for breast cancer: family history of breast cancer, personal history of breast cancer, and dense breasts. Four screening performance metrics were calculated for each age and risk group: recall rate (RR), cancer detection rate (CDR), and positive predictive values for biopsy recommended (PPV2) and biopsy performed (PPV3). Results Data from 5,986,131 screening mammograms performed between January 2008 and December 2015 in 2,647,315 women were evaluated. Overall, mean CDR was 3.69 of 1,000 (95% confidence interval: 3.64-3.74), RR was 9.89% (9.87%-9.92%), PPV2 was 20.1% (19.9%-20.4%), and PPV3 was 28.2% (27.0%-28.5%). Women aged 30 to 34 and 35 to 39 had similar CDR, RR, and PPVs, with the presence of the three evaluated risk factors associated with significantly higher CDR. Moreover, compared with a population currently recommended for screening mammography in the United States (aged 40-49 at average risk), incidence screening (at least one prior screening examination) of women aged 30 to 39 with the three evaluated risk factors has similar cancer detection rates and recall rates. Discussion Women with one or more of these three specific risk factors likely benefit from screening commencing at age 30 instead of age 40.

Rationale and Objectives The Breast Imaging-Reporting and Data System (BI-RADS) atlas defines category 5 assessments as appropriate only for lesions that are almost certainly cancer, with a positive predictive value (PPV) of ≥95%. This study aims to demonstrate the feasibility of classifying lesions at diagnostic breast imaging with sufficiently high PPV to merit category 5 assessments, and to identify those lesion descriptors that yield such a high PPV. Materials and Methods For this Health Insurance Portability and Accountability Act compliant and IRB exempt study, we reviewed diagnostic breast imaging examinations (mammography and/or ultrasound) assessed as highly suggestive of malignancy (BI-RADS category 5). Pathology diagnosis was considered the gold standard. PPV3 (biopsy performed) was calculated, and the BI-RADS descriptors for each lesion were analyzed. Results Among 22,564 consecutive diagnostic breast imaging examinations between January 2010 and September 2015, we identified 239 exams (1.1%) assessed as BI-RADS category 5 (mean age 62.5 years). Malignancy (invasive breast carcinoma and/or ductal carcinoma in situ) was diagnosed in 233 examinations (PPV3 97.5% and 95% confidence interval: 96.2%–98.8%). The most common lesion types were mass (170) and calcifications (116). Of the 220 examinations involving both mammography and ultrasound, no category 5 lesions had Conclusion In clinical practice, it is feasible to make BI-RADS category 5 assessments with the intended ≥95% PPV. To justify a category 5 assessment, at least four suspicious BI-RADS descriptors should be identified at the combination of diagnostic mammography and ultrasound examinations.

The purpose of this article is to compare commonly used breast cancer risk assessment models, describe the machine learning approach and big data in risk prediction, and summarize the potential benefits and harms of restrictive risk-based screening.The commonly used risk assessment models for breast cancer can be complex and cumbersome to use. Each model incorporates different sets of risk factors, which are weighted differently and can produce different results for the same patient. No model is appropriate for all subgroups of the general population and only one model incorporates mammographic breast density. Future development of risk prediction tools that are generalizable and simpler to use are needed in guiding clinical decisions.

Background The literature supports the use of short-interval follow-up as an alternative to biopsy for lesions assessed as probably benign, Breast Imaging Reporting and Data System (BI-RADS) category 3, with an expected malignancy rate of less than 2%. Purpose To assess outcomes from 6-, 12-, and 24-month follow-up of probably benign findings first identified at recall from screening mammography in the National Mammography Database (NMD). Materials and Methods This retrospective study included women recalled from screening mammography with BI-RADS category 3 assessment at additional evaluation from January 2009 through March 2018 from 471 NMD facilities. Only the first BI-RADS category 3 occurrence for women aged 25 years or older with no personal history of breast cancer was analyzed, with biopsy or 2-year imaging follow-up. Cancer yield and positive predictive value of biopsies performed (PPV3) were determined at each follow-up. Results Among 45 202 women (median age, 55 years; range, 25-90 years) with a BI-RADS category 3 lesion, 1574 (3.5%) underwent biopsy at the time of lesion detection, yielding 72 cancers (cancer yield, 4.6%; 72 of 1574 women). For the remaining 43 628 women who accepted surveillance, 922 were seen within 90 days (with 78 lesions biopsied and 12 [15%] classified as malignant). The women still in surveillance (31 465 of 43 381 women [72.5%]) underwent follow-up mammography at 6 months. Of 3001 (9.5%) lesions biopsied, 456 (15.2%) were malignant (cancer yield, 1.5%; 456 of 31 465 women; 95% confidence interval [CI]: 1.3%, 1.6%). Among 18 748 of 25 997 women (72.1%) in surveillance who underwent follow-up at 12 months, 1219 (6.5%) underwent biopsy with 230 (18.9%) malignant lesions found (cancer yield, 1.2%; 230 of 18 748 women; 95% CI: 1.1%, 1.4%). Through 2-year follow-up, the biopsy rate was 11.2% (4894 of 43 628 women) with a cancer yield of 1.86% (810 malignancies found among 43 628 women; 95% CI: 1.73%, 1.98%) and a PPV3 of 16.6% (810 malignancies found among 4894 women). Conclusion In the National Mammography Database, Breast Imaging Reporting and Data System (BI-RADS) category 3 use is appropriate, with 1.86% cumulative cancer yield through 2-year follow-up. Of 810 malignancies, 468 (57.8%) were diagnosed at or before 6 months, validating necessity of short-interval follow-up of mammographic BI-RADS category 3 findings. © RSNA, 2020

To compare the characteristics, outcomes, and performance metrics in women undergoing initial breast MRI screening versus subsequent screening.A retrospective database search identified screening MRIs performed at an academic practice from 2013 to 2015. MRIs were divided into two groups: (1) initial screens and (2) subsequent screens (interpreted with at least one prior MRI for comparison). Benignity was confirmed with pathology or1-year follow-up. Malignancy was confirmed by pathology. Performance metrics were calculated. Comparisons were made using Binomial and Fisher's exact tests.We observed a higher rate of abnormal interpretations (52% vs. 19%; p 0.001) and rate of biopsy (49% vs. 15%; p 0.001) in the initial versus subsequent screen group. The positive predictive value of biopsy was slightly lower at initial versus subsequent screen (17% vs. 19%, p = 0.99). However, the cancer detection rate was higher at initial than at subsequent screen (85 vs. 29/1000, p = 0.08). Sensitivity was higher at initial (100%) versus subsequent (88%) screen. However, the specificity at initial screen was low (55%) compared to subsequent screen (83%).The higher rate of abnormal interpretations in the initial versus subsequent screen group in part reflects a prevalence screening. Although we observed more abnormal interpretations in the initial screen, this was likely justified by the significantly higher cancer detection. This evidence may be used to counsel patients and referring providers on the expected higher likelihood of recall from an initial screening MRI balanced with higher detection of malignancies. Findings also highlight the importance of having comparison MRIs to decrease false positives.

Breast cancer is an important health problem for women 40-49 years old, yet screening mammography for this age group remains controversial. This article reviews recent guidelines and supporting evidence on screening mammography in women of this age group.Evidence supports the benefit of annual screening mammography in women 40-49 years old. Models of different breast cancer screening strategies consistently show the greatest breast cancer mortality reduction and life-years gained with annual screening starting when women reach 40 years old.

Rationale and Objectives Evidence is inconsistent about whether radiologists' interpretive performance on a screening mammography test set reflects their performance in clinical practice. This study aimed to estimate the correlation between test set and clinical performance and determine if the correlation is influenced by cancer prevalence or lesion difficulty in the test set. Materials and Methods This institutional review board-approved study randomized 83 radiologists from six Breast Cancer Surveillance Consortium registries to assess one of four test sets of 109 screening mammograms each; 48 radiologists completed a fifth test set of 110 mammograms 2 years later. Test sets differed in number of cancer cases and difficulty of lesion detection. Test set sensitivity and specificity were estimated using woman-level and breast-level recall with cancer status and expert opinion as gold standards. Clinical performance was estimated using women-level recall with cancer status as the gold standard. Spearman rank correlations between test set and clinical performance with 95% confidence intervals (CI) were estimated. Results For test sets with fewer cancers (N = 15) that were more difficult to detect, correlations were weak to moderate for sensitivity (woman level = 0.46, 95% CI = 0.16, 0.69; breast level = 0.35, 95% CI = 0.03, 0.61) and weak for specificity (0.24, 95% CI = 0.01, 0.45) relative to expert recall. Correlations for test sets with more cancers (N = 30) were close to 0 and not statistically significant. Conclusions Correlations between screening performance on a test set and performance in clinical practice are not strong. Test set performance more accurately reflects performance in clinical practice if cancer prevalence is low and lesions are challenging to detect.

BACKGROUND Currently, there are several different recommendations for screening mammography from major national health care organizations, including: 1) annual screening at ages 40 to 84 years; 2) screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years; and 3) biennial screening at ages 50 to 74 years. METHODS Mean values of six Cancer Intervention and Surveillance Modeling Network (CISNET) models were used to compare these three screening mammography recommendations in terms of benefits and risks. RESULTS Mean mortality reduction was greatest with the recommendation of annual screening at ages 40 to 84 years (39.6%), compared with the hybrid recommendation of screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years (30.8%), and the recommendation of biennial screening at ages 50 to 74 years (23.2%). For a single-year cohort of US women aged 40 years, assuming 100% compliance, more breast cancers deaths would be averted over their lifetime with annual screening starting at age 40 (29,369) than with the hybrid recommendation (22,829) or biennial screening ages 50-74 (17,153 based on 2009 CISNET estimates, 15,599 based on 2016 CISNET estimates). To achieve the greatest mortality benefit, this single-year cohort of women would have the greatest total number of screening mammograms, benign recalls, and benign biopsies performed over the course of screening by following annual screening starting at age 40 years (90.2 million, 6.8 million, and 481,269, respectively) than by following the hybrid recommendation (49.0 million, 4.1 million, and 286,288, respectively) or biennial screening at ages 50 to 74 years (27.3 million, 2.3 million, and 162,885, respectively). CONCLUSION CISNET models demonstrate that the greatest mortality reduction is achieved with annual screening of women starting at age 40 years. Cancer 2017;123:3673–3680. © 2017 American Cancer Society

Purpose The aim of this study was to investigate the natural history of untreated screen-detected breast cancer. Methods A prospective cohort survey of Society of Breast Imaging fellows concerning the appearance on subsequent mammography of untreated breast cancer detected on screening mammography was conducted. Results A representative sample of the 108 actively practicing Society of Breast Imaging fellows (n = 42 [39%]) participated, each reporting outcomes data from his or her entire screening mammography practice. Among all practices, 25,281 screen-detected invasive breast cancers and 9,360 cases of screen-detected ductal carcinoma in situ were reported over the past 10 years. Among these cancers, there were 240 cases of untreated invasive breast cancer and 239 cases of untreated ductal carcinoma in situ, among which zero were reported to have spontaneously disappeared or regressed at next mammography. Conclusions Among 479 untreated breast cancers detected on screening mammography, none spontaneously disappeared or regressed. An unknown percentage of these cancers represent overdiagnosis, but because all untreated screen-detected cancers were visible and suspicious for malignancy at next mammographic examination, delaying the onset of screening or increasing the interval between screenings should not reduce the frequency of overdiagnosis.

The objective of the present study is to evaluate the effect of comparison with multiple prior mammograms on the outcomes of screening mammography relative to comparison with a single prior mammogram.We retrospectively analyzed 46,288 consecutive screening mammograms performed at our institution for 22,792 women. We divided these examinations into three groups: those interpreted without comparison with prior mammograms, those interpreted in comparison with one prior examination, and those interpreted in comparison with two or more prior examinations. For each group, we determined the rate of examination recall. We also calculated the positive predictive value of recall (i.e., positive predictive value level 1 [PPV1]) and the cancer detection rate (CDR) for both the group of examinations compared with a single prior mammogram and the group compared with multiple prior mammograms. Generalized estimating equations with the logistic link function were used to determine the relative odds ratio of recall as a function of the number of comparisons, with adjustment made for age as a confounding variable. The Fisher exact test was performed to compare the PPV1 and the CDR in the different cohorts.The recall rate for mammograms interpreted without comparison with prior examinations was 16.6%, whereas that for mammograms compared with one prior examination was 7.8% and that for mammograms compared with two or more prior examinations was 6.3%. After adjustment was made for age, the odds ratio of recall for the group with multiple prior examinations relative to the group with a single prior examination was 0.864 (95% CI, 0.776-0.962; p = 0.0074). Statistically significant increases in the PPV1 of 0.05 (p = 0.0009) and in the CDR of 2.3 cases per 1000 examinations (p = 0.0481) were also noted for mammograms compared with multiple prior examinations relative to those compared with a single prior examination.Comparison with two or more prior mammograms resulted in a statistically significant reduction in the screening mammography recall rate and increases in the CDR and PPV1 relative to comparison with a single prior mammogram.

Breast density notification laws, passed in 19 states as of October 2014, mandate that patients be informed of their breast density. The purpose of this study is to assess the impact of this legislation on radiology practices, including performance of breast cancer risk assessment and supplemental screening studies. A 20-question anonymous web-based survey was emailed to radiologists in the Society of Breast Imaging between August 2013 and March 2014. Statistical analysis was performed using Fisher's exact test. Around 121 radiologists from 110 facilities in 34 USA states and 1 Canadian site responded. About 50% (55/110) of facilities had breast density legislation, 36% of facilities (39/109) performed breast cancer risk assessment (one facility did not respond). Risk assessment was performed as a new task in response to density legislation in 40% (6/15) of facilities in states with notification laws. However, there was no significant difference in performing risk assessment between facilities in states with a law and those without (p

The purposes of our study were to analyze screening mammography data submitted to the National Mammography Database (NMD) since its inception to confirm data collection feasibility, to draw parallels to data from the Breast Cancer Surveillance Consortium (BCSC), and to examine trends over time. We also retrospectively evaluated practice-level variation in terms of practice type, practice setting, census region, and annual volume.Data from 90 mammography facilities in the NMD registry were analyzed. The registry receives mammography data collected as part of standard clinical practice, including self-reported demographic information, clinical findings, screening mammography interpretation, and biopsy results. Outcome metrics calculated were cancer detection rate, recall rate, and positive predictive values for biopsy recommended (PPV2) and biopsy performed (PPV3).The NMD successfully collected and analyzed data for 3,181,437 screening mammograms performed between January 2008 and December 2012. Mean values for outcomes were cancer detection rate of 3.43 per 1000 (95% CI, 3.2-3.7), recall rate of 10% (95% CI, 9.3-10.7%), PPV2 of 18.5% (95% CI, 16.7-20.2%), and PPV3 of 29.2% (95% CI, 26.2-32.3%). No statistically significant difference was seen in performance measurements on the basis of practice type, practice setting, census region, or annual volume. NMD performance measurements parallel those reported by the BCSC.The NMD has become the fastest growing mammography registry in the United States, providing nationwide performance metrics and permitting comparison with published benchmarks. Our study shows the feasibility of using the NMD to audit mammography facilities and to provide current, ongoing benchmark data.

The current Breast Cancer Surveillance Consortium articles on performance outcomes for screening and diagnostic mammography are welcome additions to the breast imaging literature, particularly as indicators of current overall U.S. practice and how this practice has changed during the past 10 years.

Purpose The National Mammography Database (NMD) contains nearly 20 million examinations from 693 facilities; it is the largest information source for use and effectiveness of breast imaging in the United States. NMD collects demographic, imaging, interpretation, biopsy, and basic pathology results, enabling facility and physician comparison for quality improvement. However, NMD lacks treatment and clinical outcomes data. The network of state cancer registries (CRs) contains detailed pathologic, treatment, and clinical outcomes data. This pilot study assessed electronic linkage of NMD and CR data at a multicenter institution as proof of concept. Materials and Methods We obtained Quality Oversight Committee approval for this retrospective study. Data of patients diagnosed with breast cancer in 2014 and 2015 were retrieved from our NMD-approved radiology information system (RIS) and matched with reportable patients in our CR using social security number (SSN), first name (fname), last name (lname), and date of birth (DOB). Matching was repeated without SSN. Percentage and reasons for mismatch were evaluated. Results The RIS query identified 1,316 patients. CR linkage was 99.2% successful (n = 1,305 of 1,316) using SSN, fname, lname, and DOB. Eleven mismatches included four CR case-finding failures, one NMD fname error, five nonreportable in the CR, and one with correct identifiers in both databases. Without SSN, linkage was 97.3% successful (n = 1,281 of 1,316); name errors accounted for 19 and DOB accounted for 5 additional mismatches. Conclusion Using common data elements, linkage between the NMD and state CRs may be feasible and could provide critical outcomes information to advance accurate assessment of breast imaging in the United States.

The purpose of this study was to determine the prevalence of very strong family history and extremely dense tissue in women 40-49 years old with breast cancer detected on screening mammography.All cancers detected by screening mammography at our institution between January 1997 and November 2012 in 40- to 49-year-old women were retrospectively identified. Those with a personal history of breast cancer were excluded. Family history, breast density, type of malignancy, hormone receptor status, and lymph node status were recorded.One hundred thirty-six cases of breast cancer were identified on screening mammography in 40- to 49-year-old women; 50% were invasive cancers, and 50%, ductal carcinoma in situ. Very strong family history was absent in 88%, and extremely dense breast tissue was absent in 86%. Seventy-six percent of patients had neither very strong family history nor extremely dense breasts, including 79% of the cases of invasive cancers, of which 25% had axillary nodal involvement and 89% were estrogen receptor positive.Very strong family history and extremely dense breast tissue were absent in most 40- to 49-year-old women with breast cancer detected at screening mammography. These cancers were frequently invasive (often with nodal metastases) and treatable (hormone receptor positive). Reducing the number of women to be screened in this age group by using this risk-based approach would reduce the number of screen-detected cancers by more than 75%, thereby precluding the benefit of mortality reduction. Even using a risk-based strategy with an expanded definition of high risk that included any first-degree family history, extremely dense tissue, or both, 66% of malignancies would still be missed.

Early detection decreases breast cancer mortality. The ACR recommends annual mammographic screening beginning at age 40 for women of average risk. Higher-risk women should start mammographic screening earlier and may benefit from supplemental screening modalities. For women with genetics-based increased risk (and their untested first-degree relatives), with a calculated lifetime risk of 20% or more or a history of chest or mantle radiation therapy at a young age, supplemental screening with contrast-enhanced breast MRI is recommended. Breast MRI is also recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed by age 50. Others with histories of breast cancer and those with atypia at biopsy should consider additional surveillance with MRI, especially if other risk factors are present. Ultrasound can be considered for those who qualify for but cannot undergo MRI. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at higher risk can be identified and can benefit from supplemental screening.

OBJECTIVE. Older women undergoing regular mammography experience significant reductions in breast cancer mortality, except in women with severe comorbidities or limited life expectancy. Optimizing screening strategies requires informed discussions of benefits and risks given each woman's health status. CONCLUSION. This article will review the benefits and risks of screening mammography in women older than 75 years within the context of life expectancy and comorbidities and summarize the current recommendations from professional organizations for screening mammography in older women.

The purposes of this article are to summarize breast cancer screening recommendations and discuss their differences and similarities and to explain the differences between two national databases to aid in interpretation of their benchmarks.The American College of Radiology, American Cancer Society, and U.S. Preventive Services Task Force all agree that annual mammography beginning at age 40 saves the most lives, and all acknowledge a woman's right to choose when to begin and stop screening. The National Mammography Database (NMD) differs from the Breast Cancer Surveillance Consortium database in that it acquires data using the same approach used by almost all mammography facilities in the United States. Therefore, NMD benchmarks, which include standard metrics, provide more meaningful comparisons to help mammography facilities and radiologists improve performance.

Breast cancer is the most common non-skin cancer and the second leading cause of cancer death for women in the United States. Before the introduction of widespread mammographic screening in the mid-1980s, the death rate from breast cancer in the US had remained unchanged for more than 4 decades. Since 1990, the death rate has declined by at least 38%. Much of this change is attributed to early detection with mammography. ACR breast cancer screening experts have reviewed data from RCTs, observational studies, US screening data, and other peer-reviewed literature to update our recommendations. Mammography screening has consistently been shown to significantly reduce breast cancer mortality over a variety of study designs. The ACR recommends annual mammography screening starting at age 40 for women of average risk of developing breast cancer. Our recommendation is based on maximizing proven benefits, which include a substantial reduction in breast cancer mortality afforded by regular screening and improved treatment options for those diagnosed with breast cancer. The risks associated with mammography screening are also considered to assist women in making an informed choice.

The practice of breast imaging has transitioned through a wide variety of technologic advances from the early days of direct-exposure film mammography to xeromammography to screen-film mammography to the current era of full-field digital mammography and digital breast tomosynthesis. Along with these technologic advances, organized screening, federal regulations based on the Mammography Quality Standards Act, and the development of the American College of Radiology Breast Imaging Reporting and Data System have helped to shape the specialty of breast imaging. With the development of breast ultrasonography and breast magnetic resonance imaging, both complementary to mammography, additional algorithms for diagnostic workup and screening high-risk subgroups of women have emerged. A substantial part of breast imaging practice these days also involves breast interventional procedures-both percutaneous biopsy to obtain tissue diagnosis and localization procedures to guide surgical excision. This article reviews the evolution of breast imaging starting from a historical perspective and progressing to the present day.

ObjectiveThe objective of our study was to conduct a randomized controlled trial of educational interventions that were created to improve performance of screening mammography interpretation.Materials and methodsWe randomly assigned physicians who interpret mammography to one of three groups: self-paced DVD, live expert-led educational seminar, or control. The DVD and seminar interventions used mammography cases of varying difficulty and provided associated teaching points. Interpretive performance was compared using a pretest-posttest design. Sensitivity, specificity, and positive predictive value (PPV) were calculated relative to two outcomes: cancer status and consensus of three experts about recall. The performance measures for each group were compared using logistic regression adjusting for pretest performance.ResultsOne hundred two radiologists completed all aspects of the trial. After adjustment for preintervention performance, the odds of improved sensitivity for correctly identifying a lesion relative to expert recall were 1.34 times higher for DVD participants than for control subjects (95% CI, 1.00-1.81; p = 0.050). The odds of an improved PPV for correctly identifying a lesion relative to both expert recall (odds ratio [OR] = 1.94; 95% CI, 1.24-3.05; p = 0.004) and cancer status (OR = 1.81; 95% CI, 1.01-3.23; p = 0.045) were significantly improved for DVD participants compared with control subjects, with no significant change in specificity. For the seminar group, specificity was significantly lower than the control group (OR relative to expert recall = 0.80; 95% CI, 0.64-1.00; p = 0.048; OR relative to cancer status = 0.79; 95% CI, 0.65-0.95; p = 0.015).ConclusionIn this randomized controlled trial, the DVD educational intervention resulted in a significant improvement in screening mammography interpretive performance on a test set, which could translate into improved interpretative performance in clinical practice.

Rationale and Objectives Test sets for assessing and improving radiologic image interpretation have been used for decades and typically evaluate performance relative to gold standard interpretations by experts. To assess test sets for screening mammography, a gold standard for whether a woman should be recalled for additional workup is needed, given that interval cancers may be occult on mammography and some findings ultimately determined to be benign require additional imaging to determine if biopsy is warranted. Using experts to set a gold standard assumes little variation occurs in their interpretations, but this has not been explicitly studied in mammography. Materials and Methods Using digitized films from 314 screening mammography exams ( n = 143 cancer cases) performed in the Breast Cancer Surveillance Consortium, we evaluated interpretive agreement among three expert radiologists who independently assessed whether each examination should be recalled, and the lesion location, finding type (mass, calcification, asymmetric density, or architectural distortion), and interpretive difficulty in the recalled images. Results Agreement among the three expert pairs for recall/no recall was higher for cancer cases (mean 74.3 ± 6.5) than for noncancers (mean 62.6 ± 7.1). Complete agreement on recall, lesion location, finding type and difficulty ranged from 36.4% to 42.0% for cancer cases and from 43.9% to 65.6% for noncancer cases. Two of three experts agreed on recall and lesion location for 95.1% of cancer cases and 91.8% of noncancer cases, but all three experts agreed on only 55.2% of cancer cases and 42.1% of noncancer cases. Conclusion Variability in expert interpretive is notable. A minimum of three independent experts combined with a consensus should be used for establishing any gold standard interpretation for test sets, especially for noncancer cases.

Purpose To determine the accuracy of a probably benign assessment of non-palpable breast lesions (BI-RADS category 3) at mammography and/or ultrasound with immediate histological work-up. Materials and methods Stereotactic or ultrasound guided core needle breast biopsy (NBB) was performed to evaluate 288 lesions, which were prospectively assessed as BI-RADS category 3. Imaging findings included 195 masses, 73 calcification cases, 16 focal asymmetries, and four architectural distortion cases. After NBB, patients underwent either open surgical biopsy (OSB) (n = 204) or mammographic follow-up (n = 84) for at least 24 months. Histological results of NBB were compared with those of OSB. Results Three of the 288 lesions (1.0%) proved to be malignant at histological work-up, two of them were ductal carcinoma in situ (DCIS) and one of them was an invasive carcinoma. NBB revealed invasive carcinoma in 1/288 (0.35%) and atypical ductal hyperplasia (ADH) in 13/288 (4.5%) lesions. OSB revealed DCIS in 2/204 (1%) and invasive carcinoma in 1/204 (0.5%) lesions. The two DCIS were underestimated as ADH by NBB. The remaining 285 (99%) lesions proved to be benign at OSB or remained stable during follow-up. Conclusion Confirmed by tissue diagnosis, the low likelihood of malignancy of prospectively assessed probably benign lesions is below the 2% threshold established for BI-RADS category 3. Imaging follow-up is a safe and effective alternative to immediate histological work-up for such lesions.

To compare stereoscopic digital mammography (DM) with standard DM for the rate of patient recall and the detection of cancer in a screening population at elevated risk for breast cancer.Starting in September 2004 and ending in December 2007, this prospective HIPAA-compliant, institutional review board-approved screening trial, with written informed consent, recruited female patients at elevated risk for breast cancer (eg, personal history of breast cancer or breast cancer in a close relative). A total of 1298 examinations from 779 patients (mean age, 58.6 years; range, 32-91 years) comprised the analyzable data set. A paired study design was used, with each enrolled patient serving as her own control. Patients underwent both DM and stereoscopic DM examinations in a single visit, findings of which were interpreted independently by two experienced radiologists, each using a Breast Imaging Reporting and Data System (BI-RADS) assessment (BI-RADS category 0, 1, or 2). All patients determined to have one or more findings with either or both modalities were recalled for standard diagnostic evaluation. The results of 1-year follow-up or biopsy were used to determine case truth.Compared with DM, stereoscopic DM showed significantly higher specificity (91.2% [1167 of 1279] vs 87.8% [1123 of 1279]; P = .0024) and accuracy (90.9% [1180 of 1298] vs 87.4% [1135 of 1298]; P = .0023) for detection of cancer. Sensitivity for detection of cancer was not significantly different for stereoscopic DM (68.4% [13 of 19]) compared with DM (63.2% [12 of 19], P .99). The recall rate for stereoscopic DM was 9.6% (125 of 1298) and that for DM was 12.9% (168 of 1298) (P = .0018).Compared with DM, stereoscopic DM significantly improved specificity for detection of cancer, while maintaining comparable sensitivity. The recall rate was significantly reduced with stereoscopic DM compared with DM.http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120382/-/DC1.

The purpose of this study was to identify potential BI-RADS 3 mass descriptors on breast magnetic resonance imaging by systematically defining positive predictive values (PPV). In a blinded retrospective review of BI-RADS 4 masses, reader 1 identified 132 masses and reader 2 identified 76 masses. PPV for mass descriptors and for descriptor combinations was determined. No mass descriptor resulted in a PPV ≤2% (BI-RADS 3 threshold). Descriptors with the lowest PPVs were circumscribed margin (8%), rim internal enhancement and persistent kinetics (13% each), and oval shape (15%). The results demonstrate the difficulty in transferring the theoretical concept of lesion surveillance to systematic clinical use.

Currently, there are several different recommendations for screening mammography from major national health care organizations, including: 1) annual screening at ages 40 to 84 years; 2) screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years; and 3) biennial screening at ages 50 to 74 years.Mean values of six Cancer Intervention and Surveillance Modeling Network (CISNET) models were used to compare these three screening mammography recommendations in terms of benefits and risks.Mean mortality reduction was greatest with the recommendation of annual screening at ages 40 to 84 years (39.6%), compared with the hybrid recommendation of screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years (30.8%), and the recommendation of biennial screening at ages 50 to 74 years (23.2%). For a single-year cohort of US women aged 40 years, assuming 100% compliance, more breast cancers deaths would be averted over their lifetime with annual screening starting at age 40 (29,369) than with the hybrid recommendation (22,829) or biennial screening ages 50-74 (17,153 based on 2009 CISNET estimates, 15,599 based on 2016 CISNET estimates). To achieve the greatest mortality benefit, this single-year cohort of women would have the greatest total number of screening mammograms, benign recalls, and benign biopsies performed over the course of screening by following annual screening starting at age 40 years (90.2 million, 6.8 million, and 481,269, respectively) than by following the hybrid recommendation (49.0 million, 4.1 million, and 286,288, respectively) or biennial screening at ages 50 to 74 years (27.3 million, 2.3 million, and 162,885, respectively).CISNET models demonstrate that the greatest mortality reduction is achieved with annual screening of women starting at age 40 years. Cancer 2017;123:3673-3680. © 2017 American Cancer Society.

PurposeTo compare cancer recurrence outcomes on the basis of compliant semiannual versus noncompliant annual ipsilateral mammographic surveillance following breast conservation therapy (BCT).Materials and methodsA HIPAA-compliant retrospective review was performed of post-BCT examinations from 1997 through 2008 by using a deidentified database. The Committee on Human Research did not require institutional review board approval for this study, which was considered quality assurance. Groups were classified according to compliance with institutional post-BCT protocol, which recommends semiannual mammographic examinations of the ipsilateral breast for 5 years. A compliant semiannual examination was defined as an examination with an interval of 0-9 months, although no examination had intervals less than 3 months. A noncompliant annual examination was defined as an examination with an interval of 9-18 months. Cancer recurrence outcomes were compared on the basis of the last examination interval leading to diagnosis.ResultsInitially, a total of 10 750 post-BCT examinations among 2329 asymptomatic patients were identified. Excluding initial mammographic follow-up, there were 8234 examinations. Of these, 7169 examinations were semiannual with 94 recurrences detected and 1065 examinations were annual with 15 recurrences detected. There were no differences in demographic risk factors or biopsy rates. Recurrences identified at semiannual intervals were significantly less advanced than those identified at annual intervals (stage I vs stage II, P = .04; stage 0 + stage I vs stage II, P = .03). Nonsignificant findings associated with semiannual versus annual intervals included smaller tumor size (mean, 11.7 vs 15.3 mm; P = .15) and node negativity (98% vs 91%, P = .28).ConclusionResults suggest that a semiannual interval is preferable for ipsilateral mammographic surveillance, allowing detection of a significantly higher proportion of cancer recurrences at an earlier stage than noncompliant annual surveillance.

To investigate the association between radiologist interpretive volume and diagnostic mammography performance in community-based settings.This study received institutional review board approval and was HIPAA compliant. A total of 117,136 diagnostic mammograms that were interpreted by 107 radiologists between 2002 and 2006 in the Breast Cancer Surveillance Consortium were included. Logistic regression analysis was used to estimate the adjusted effect on sensitivity and the rates of false-positive findings and cancer detection of four volume measures: annual diagnostic volume, screening volume, total volume, and diagnostic focus (percentage of total volume that is diagnostic). Analyses were stratified by the indication for imaging: additional imaging after screening mammography or evaluation of a breast concern or problem.Diagnostic volume was associated with sensitivity; the odds of a true-positive finding rose until a diagnostic volume of 1000 mammograms was reached; thereafter, they either leveled off (P.001 for additional imaging) or decreased (P = .049 for breast concerns or problems) with further volume increases. Diagnostic focus was associated with false-positive rate; the odds of a false-positive finding increased until a diagnostic focus of 20% was reached and decreased thereafter (P.024 for additional imaging and P.001 for breast concerns or problems with no self-reported lump). Neither total volume nor screening volume was consistently associated with diagnostic performance.Interpretive volume and diagnostic performance have complex multifaceted relationships. Our results suggest that diagnostic interpretive volume is a key determinant in the development of thresholds for considering a diagnostic mammogram to be abnormal. Current volume regulations do not distinguish between screening and diagnostic mammography, and doing so would likely be challenging.

Rationale and Objectives To examine whether an intervention strategy consisting of a tailored web-based intervention, which provides individualized audit data with peer comparisons and other data that can affect recall, can assist radiologists in setting goals for reducing unnecessary recall. Materials and Methods In a multisite randomized controlled study, we used a tailored web-based intervention to assess radiologists’ ability to set goals to improve interpretive performance. The intervention provided peer comparison audit data, profiled breast cancer risk in each radiologist’s respective patient populations, and evaluated the possible impact of medical malpractice concerns. We calculated the percentage of radiologists who would consider changing their recall rates, and examined the specific goals they set to reduce recall rates. We describe characteristics of radiologists who developed realistic goals to reduce their recall rates, and their reactions to the importance of patient risk factors and medical malpractice concerns. Results Forty-one of 46 radiologists (89.1%) who started the intervention completed it. Thirty-one (72.1%) indicated they would like to change their recall rates and 30 (69.8%) entered a text response about changing their rates. Sixteen of the 30 (53.3%) radiologists who included a text response set realistic goals that would likely result in reducing unnecessary recall. The actual recall rates of those who set realistic goals were not statistically different from those who did not (13.8% vs. 15.1%, respectively). The majority of selected goals involved re-reviewing cases initially interpreted as Breast Imaging Reporting and Data System category 0. More than half of radiologists who commented on the influence of patient risk (56.3%) indicated that radiologists planned to pay more attention to risk factors, and 100% of participants commented on concerns radiologists have about malpractice with the primary concern (37.5%) being fear of lawsuits. Conclusions Interventions designed to reduce unnecessary recall can succeed in assisting radiologists to develop goals that may ultimately reduce unnecessary recall.

To examine whether U.S. radiologists' interpretive volume affects their screening mammography performance.Annual interpretive volume measures (total, screening, diagnostic, and screening focus [ratio of screening to diagnostic mammograms]) were collected for 120 radiologists in the Breast Cancer Surveillance Consortium (BCSC) who interpreted 783 965 screening mammograms from 2002 to 2006. Volume measures in 1 year were examined by using multivariate logistic regression relative to screening sensitivity, false-positive rates, and cancer detection rate the next year. BCSC registries and the Statistical Coordinating Center received institutional review board approval for active or passive consenting processes and a Federal Certificate of Confidentiality and other protections for participating women, physicians, and facilities. All procedures were compliant with the terms of the Health Insurance Portability and Accountability Act.Mean sensitivity was 85.2% (95% confidence interval [CI]: 83.7%, 86.6%) and was significantly lower for radiologists with a greater screening focus (P = .023) but did not significantly differ by total (P = .47), screening (P = .33), or diagnostic (P = .23) volume. The mean false-positive rate was 9.1% (95% CI: 8.1%, 10.1%), with rates significantly higher for radiologists who had the lowest total (P = .008) and screening (P = .015) volumes. Radiologists with low diagnostic volume (P = .004 and P = .008) and a greater screening focus (P = .003 and P = .002) had significantly lower false-positive and cancer detection rates, respectively. Median invasive tumor size and proportion of cancers detected at early stages did not vary by volume.Increasing minimum interpretive volume requirements in the United States while adding a minimal requirement for diagnostic interpretation could reduce the number of false-positive work-ups without hindering cancer detection. These results provide detailed associations between mammography volumes and performance for policymakers to consider along with workforce, practice organization, and access issues and radiologist experience when reevaluating requirements.

Rationale and Objectives To examine the feasibility of and satisfaction with a tailored web-based intervention designed to decrease radiologists’ recommendation of inappropriate additional work-up after a screening mammogram. Materials and Methods We developed a web-based educational intervention designed to reduce inappropriate recall. Radiologists were randomly assigned to participate in an early intervention group or a late (control) intervention group, the latter of which served as a control for a 9-month follow-up period, after which they were invited to participate in the intervention. Intervention content was derived from our prior research and included three modules: 1) an introduction to audit statistics for mammography performance; 2) a review of data showing radiologists’ inflated perceptions of medical malpractice risks related to breast imaging, and 3) a review of data on breast cancer risk among women seen in their practices. Embedded within the intervention were individualized audit data for each participating radiologists obtained from the national Breast Cancer Surveillance Consortium. Results Seventy-four radiologists (37.8%; 74/196) consented to the intervention, which was completed by 67.5% (27/40) of those randomized to the early intervention group and 41.2% (14/34) of those randomized to the late (control) group. Thus, a total of 41 (55%) completed the intervention. On average, three log-ins were used to complete the program (range 1–14), which took approximately 1 hour. Ninety-five percent found the program moderately to very helpful in understanding how to calculate basic performance measures. Ninety-three percent found viewing their own performance measures moderately to very helpful, and 83% reported it being moderately to very important to learn that the breast cancer risk in their screening population program was lower than perceived. The percentage of radiologists who reported that the risk of medical malpractice influences their recall rates dropped from 36.3% preintervention to 17.8% after intervention with a similar drop in perceived influence of malpractice risk on their recommendations for breast biopsy (36.4 to 17.3%). More than 75% of radiologists answered the postintervention knowledge questions correctly, and the percent of time spent in breast imaging did not appear to influence responses. The majority (>92%) of participants correctly responded that the target recall rate in the United States is 9%. The mean self-reported recall rates were 13.0 for radiologists spending 40% time spent in breast imaging, which was highly correlated with their actual recall rates (0.991; P Conclusions Radiologists who begin an internet-based tailored intervention designed to help reduce unnecessary recall will likely complete it, although only 55% who consented to the study actually undertook the intervention. Participants found the program useful in helping them understand why their recall rates may be elevated.

The aim of this study was to examine radiologists' use and perceptions of computer-aided detection (CAD) and double reading for screening mammography interpretation.A mailed survey of 257 community radiologists participating in the national Breast Cancer Surveillance Consortium was used to assess perceptions and practices related to CAD and double reading. Latent class analysis was used to classify radiologists' overall perceptions of CAD and double reading on the basis of their agreement or disagreement with specific statements about CAD and double reading.Most radiologists (64%) reported using CAD for more than half the screening mammograms they interpreted, but only5% reported double reading that much. More radiologists perceived that double reading improved cancer detection rates compared to CAD (74% vs 55% reported), whereas fewer radiologists thought that double reading decreased recall rates compared to CAD (50% vs 65% reported). Radiologists with the most favorable perceptions of CAD were more likely to think that CAD improved cancer detection rates without taking too much time compared to radiologists with the most unfavorable overall perceptions. In latent class analysis, an overall favorable perception of CAD was significantly associated with the use of CAD (81%), a higher percentage of workload in screening mammography (80%), academic affiliation (71%), and fellowship training (58%). Perceptions of double reading that were most favorable were associated with academic affiliation (98%).Radiologists' perceptions were more favorable toward double reading by a second clinician than by a computer, although fewer used double reading in their own practice. The majority of radiologists perceived both CAD and double reading at least somewhat favorably, although for largely different reasons.

The purpose of this study is to review the clinical and pathologic outcomes for cases of solitary dilated duct identified at mammography.For all screening mammography examinations during a 22-year period and all diagnostic mammography examinations during the last 10 of these years, the radiologists recorded the principal finding of each abnormal mammographic examination during image interpretation. Only examinations with the recorded finding of solitary dilated duct were studied. We examined radiology records to determine imaging follow-up and pathology records to determine histologic diagnosis, and we performed linkage with our regional tumor registry to identify cancers not biopsied at our institution.The finding of solitary dilated duct was recorded for nine (0.0038%) of 235,209 consecutive screenings and for 12 (0.041%) of 29,267 consecutive diagnostic mammography examinations. Five screening and five diagnostic cases were stable at follow-up (minimum interval, 2 years) and did not undergo biopsy; tumor registry linkage showed no subsequent cancer diagnosis. Biopsy was performed for four (44%) of nine screening and seven (58%) of 12 diagnostic cases. One cancer each (ductal carcinoma in situ) was identified from the screening and diagnostic populations, yielding positive predictive values of 11% (1/9) and 8% (1/12), respectively.Solitary dilated duct is a rare mammographic finding, this series being the largest reported to date. Although few cases are studied, solitary dilated duct appears to have a greater than 2% likelihood of malignancy, sufficiently high to suggest that a suspicious (BI-RADS 4a) assessment may be appropriate.

To examine changes in screening mammogram interpretation as radiologists with and radiologists without fellowship training in breast imaging gain clinical experience.In an institutional review board-approved HIPAA-compliant study, the performance of 231 radiologists who interpreted screen-film screening mammograms from 1996 to 2005 at 280 facilities that contribute data to the Breast Cancer Surveillance Consortium was examined. Radiologists' demographic data and clinical experience levels were collected by means of a mailed survey. Mammograms were grouped on the basis of how many years the interpreting radiologist had been practicing mammography, and the influence of increasing experience on performance was examined separately for radiologists with and those without fellowship training in breast imaging, taking into account case-mix and radiologist-level differences.A total of 1 599 610 mammograms were interpreted during the study period. Performance for radiologists without fellowship training improved most during their 1st 3 years of clinical practice, when the odds of a false-positive reading dropped 11%-15% per year (P.015) with no associated decrease in sensitivity (P.89). The number of women recalled per breast cancer detected decreased from 33 for radiologists in their 1st year of practice to 24 for radiologists with 3 years of experience to 19 for radiologists with 20 years of experience. Radiologists with fellowship training in breast imaging experienced no learning curve and reached desirable goals during their 1st year of practice.Radiologists' interpretations of screening mammograms improve during their first few years of practice and continue to improve throughout much of their careers. Additional residency training and targeted continuing medical education may help reduce the number of work-ups of benign lesions while maintaining high cancer detection rates.

Fellowship training in breast imaging was the only radiologists’ characteristic significantly associated with greater sensitivity and higher overall accuracy; however, fellowship-trained radiologists also had significantly higher false-positive rates.

Interpretive performance of screening mammography varies substantially by facility, but performance of diagnostic interpretation has not been studied.Facilities performing diagnostic mammography within three registries of the Breast Cancer Surveillance Consortium were surveyed about their structure, organization, and interpretive processes. Performance measurements (false-positive rate, sensitivity, and likelihood of cancer among women referred for biopsy [positive predictive value of biopsy recommendation {PPV2}]) from January 1, 1998, through December 31, 2005, were prospectively measured. Logistic regression and receiver operating characteristic (ROC) curve analyses, adjusted for patient and radiologist characteristics, were used to assess the association between facility characteristics and interpretive performance. All statistical tests were two-sided.Forty-five of the 53 facilities completed a facility survey (85% response rate), and 32 of the 45 facilities performed diagnostic mammography. The analyses included 28 100 diagnostic mammograms performed as an evaluation of a breast problem, and data were available for 118 radiologists who interpreted diagnostic mammograms at the facilities. Performance measurements demonstrated statistically significant interpretive variability among facilities (sensitivity, P = .006; false-positive rate, P.001; and PPV2, P.001) in unadjusted analyses. However, after adjustment for patient and radiologist characteristics, only false-positive rate variation remained statistically significant and facility traits associated with performance measures changed (false-positive rate = 6.5%, 95% confidence interval [CI] = 5.5% to 7.4%; sensitivity = 73.5%, 95% CI = 67.1% to 79.9%; and PPV2 = 33.8%, 95% CI = 29.1% to 38.5%). Facilities reporting that concern about malpractice had moderately or greatly increased diagnostic examination recommendations at the facility had a higher false-positive rate (odds ratio [OR] = 1.48, 95% CI = 1.09 to 2.01) and a non-statistically significantly higher sensitivity (OR = 1.74, 95% CI = 0.94 to 3.23). Facilities offering specialized interventional services had a non-statistically significantly higher false-positive rate (OR = 1.97, 95% CI = 0.94 to 4.1). No characteristics were associated with overall accuracy by ROC curve analyses.Variation in diagnostic mammography interpretation exists across facilities. Failure to adjust for patient characteristics when comparing facility performance could lead to erroneous conclusions. Malpractice concerns are associated with interpretive performance.

Purpose: To evaluate the risk of cancer (positive predictive value [PPV]) associated with specific findings (mass, calcifications, architectural distortion, asymmetry) in mammographic examinations with abnormal results, to determine the distribution of these findings in examinations in which the patients received a diagnosis of cancer and examinations in which the patients did not, and to analyze PPV variation according to radiologist and patient factors. Materials and Methods: HIPAA-compliant institutional review board approval was obtained. PPV of mammographic findings was evaluated in a prospective cohort of 10 262 women who underwent 10 641 screening or diagnostic mammographic examinations with abnormal results between January 1998 and December 2002 in the San Francisco Mammography Registry. The cohort was linked with the Surveillance Epidemiology and End Results program to determine cancer status among these women. PPVs were calculated for each finding and were stratified according to patient characteristics, cancer type, and radiologist reader. Results: Cases of breast cancer (n = 1552) were identified (invasive, n = 1287; ductal carcinoma in situ, n = 270); in five, both kinds of breast cancer were recorded. Overall, of the number of interpretations, masses were most frequently noted in 56%, followed by calcifications in 29%, asymmetry in 12%, and architectural distortion in 4%. Masses, calcifications, architectural distortion, and developing asymmetry demonstrated similar PPVs in screening examinations (9.7%, 12.7%, 10.2%, and 7.4%, respectively), whereas one-view-only and focal asymmetry demonstrated lower PPVs (3.6% and 3.7%, respectively) and were a frequent reason for an abnormal result (42%). Overall, one (5%) in 20 invasive cancers was identified with asymmetry, one (6%) in 16 invasive cancers was identified with architectural distortion, one (21%) in five invasive cancers was identified with calcifications, and two (68%) in three invasive cancers were identified with a mass. Conclusion: Five percent of invasive cancers were identified with asymmetry, and asymmetry is more weakly associated with cancer in screening examinations than are mass, calcifications, and architectural distortion. © RSNA, 2009

Wie bereits in ► Kap. 22 (Punkt 16, 17 und 18) wird die Interpretation der aktuellen Untersuchung bei einer unvollstandigen Screening-Bewertung (BI-RADS®-Kategorie 0) mit der Empfehlung, zum Vergleich Voraufnahmen abzuwarten, aufgeschoben, bis die Information aus der/den Voruntersuchung( en) auch vorliegt.

Denken Sie daran, dass bei Screening-Untersuchungen die BI-RADS®-Kategorien 0, 4 und 5 positive, dagegen die BI-RADS®-Kategorien 1 und 2 negative Bewertungen sind. Fuhrt man eine Online-Befundung fur eine Screening-Mammografie oder eine Screening-Sonografie mit Aufzeichnung zusatzlicher diagnostischer Bilder durch, dann wird die Screening-Komponente der Untersuchung als Audit-positiv (gleich der Wiedereinbestellung fur zusatzliche Bildgebung, BI-RADS-Kategorie 0) gewertet, egal ob gesonderte Screening- und diagnostische Befunde herausgegeben werden.

Zunachst sei ein lexikalischer Uberblick zu den Beurteilungskriterien vorangestellt (◘ Tab. 2.1)

Das Folgende ist ein Glossar statistischer Termini, die zum Basis-Audit und zum umfassenden Audit der Praxis der Mammabildgebung verwendet werden; beides wird detailliert im Anschluss an das Glossar beschrieben.