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Background: Hepatocellular carcinoma (HCC) surveillance is underutilized, with Methods: We conducted a retrospective cohort study of individuals with cirrhosis using claims data from Medicare, Medicaid, and private insurance plans in North Carolina. We included individuals ≥ 18 years with a first occurrence of an ICD-9/10 code for cirrhosis between January 1, 2010, and June 30, 2018. The outcome was HCC surveillance by abdominal ultrasound, CT, or MRI. We estimated 1- and 2-year cumulative incidences for HCC surveillance and assessed longitudinal adherence to surveillance by computing the proportion of time covered (PTC). Results: Among 46,052 individuals, 71% were enrolled through Medicare, 15% through Medicaid, and 14% through private insurance. The overall 1-year cumulative incidence of HCC surveillance was 49% and the 2-year cumulative incidence was 55%. For those with an initial screen in the first 6 months of their cirrhosis diagnosis, the median 2-year PTC was 67% (Q1, 38%; Q3, 100%). Conclusions: HCC surveillance initiation after cirrhosis diagnosis remains low, though it has improved slightly over time, particularly among individuals with Medicaid. Impact: This study provides insight into recent trends in HCC surveillance and highlights areas to target for future interventions, particularly among patients with nonviral etiologies.

PurposeThe aim of this study was to develop a prioritization strategy for scheduling immediate screening mammographic interpretation and possible diagnostic evaluation.MethodsA population-based cohort with screening mammograms performed from 2012 to 2020 at 126 radiology facilities from 7Breast Cancer Surveillance Consortium registries was identified. Classification trees identified combinations of clinical history (age, BI-RADS® density, time since prior mammogram, history of false-positive recall or biopsy result), screening modality (digital mammography, digital breast tomosynthesis), and facility characteristics (profit status, location, screening volume, practice type, academic affiliation) that grouped screening mammograms by recall rate, with ≥12/100 considered high and ≥16/100 very high. An efficiency ratio was estimated as the percentage of recalls divided by the percentage of mammograms.ResultsThe study cohort included 2,674,051 screening mammograms in 925,777 women, with 235,569 recalls. The most important predictor of recall was time since prior mammogram, followed by age, history of false-positive recall, breast density, history of benign biopsy, and screening modality. Recall rates were very high for baseline mammograms (21.3/100; 95% confidence interval, 19.7-23.0) and high for women with ≥5 years since prior mammogram (15.1/100; 95% confidence interval, 14.3-16.1). The 9.2% of mammograms in subgroups with very high and high recall rates accounted for 19.2% of recalls, an efficiency ratio of 2.1 compared with a random approach. Adding women

Background: Machine learning (ML) approaches facilitate risk prediction model development using high-dimensional predictors and higher-order interactions at the cost of model interpretability and transparency. We compared the relative predictive performance of statistical and ML models to guide modeling strategy selection for surveillance mammography outcomes in women with a personal history of breast cancer (PHBC). Methods: We cross-validated seven risk prediction models for two surveillance outcomes, failure (breast cancer within 12 months of a negative surveillance mammogram) and benefit (surveillance-detected breast cancer). We included 9,447 mammograms (495 failures, 1,414 benefits, and 7,538 nonevents) from years 1996 to 2017 using a 1:4 matched case–control samples of women with PHBC in the Breast Cancer Surveillance Consortium. We assessed model performance of conventional regression, regularized regressions (LASSO and elastic-net), and ML methods (random forests and gradient boosting machines) by evaluating their calibration and, among well-calibrated models, comparing the area under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CI). Results: LASSO and elastic-net consistently provided well-calibrated predicted risks for surveillance failure and benefit. The AUCs of LASSO and elastic-net were both 0.63 (95% CI, 0.60–0.66) for surveillance failure and 0.66 (95% CI, 0.64–0.68) for surveillance benefit, the highest among well-calibrated models. Conclusions: For predicting breast cancer surveillance mammography outcomes, regularized regression outperformed other modeling approaches and balanced the trade-off between model flexibility and interpretability. Impact: Regularized regression may be preferred for developing risk prediction models in other contexts with rare outcomes, similar training sample sizes, and low-dimensional features.

The aim of this study was to determine the frequency, components of, and factors associated with shared decision-making (SDM) discussions according to electronic health record (EHR) documentation among individuals undergoing lung cancer screening (LCS).A prospective observational cohort study was conducted of individuals undergoing LCS between February 2015 and June 2020 at four LCS centers. The primary outcome was EHR-documented SDM, defined using Medicare-designated components. A multivariable logistic regression model was used to examine predictors of EHR-documented SDM. A secondary outcome was agreement of individual's self-report of SDM and EHR-documented SDM, evaluated using Cohen's κ statistic.Among screened individuals, 41.9% (243 of 580) had EHR-documented SDM, and 71.1% (295 of 415) had self-reported SDM. Decision aids were used in 55.6% of EHR-documented SDM encounters (135 of 243), and 21.8% of documented SDM encounters (53 of 243) included all Medicare-designated components. SDM was documented more frequently in individuals with body mass index ≥ 25 versus25 kg/mAlthough EHR-documented SDM occurred in fewer than half of individuals undergoing LCS, self-reported SDM rates were higher, suggesting that SDM may be underdocumented in the EHR. In addition, EHR-documented SDM was more likely in individuals with higher body mass index and those referred for LCS by pulmonary clinicians. These findings indicate areas for improvement in the implementation and documentation of SDM.

Supplementary Table 8 includes one-year cumulative incidences for HCC surveillance overall and by insurance type, by calendar year of cirrhosis diagnosis (% and 95% confidence intervals).

Supplementary Table 12 includes the one-year cumulative incidences for HCC surveillance overall and by insurance type, by calendar year of cirrhosis diagnosis, excluding individuals with decompensated cirrhosis (% and 95% confidence intervals).

Supplementary Table 7 includes baseline characteristics of individuals with cirrhosis eligible for HCC surveillance – Medicare only (N, %) (N=32,723).

The Supplementary Methods includes detailed descriptions for calculating the Proportion of Time Covered measures.

Supplementary Table 5 includes baseline characteristics of individuals with cirrhosis eligible for HCC surveillance – private insurance only (N, %) (N=6,530).

Supplementary Table 9 includes two-year cumulative incidences for HCC surveillance overall and by insurance type, by calendar year of cirrhosis diagnosis (% and 95% confidence intervals).

Supplementary Table 6 includes baseline characteristics of individuals with cirrhosis eligible for HCC surveillance – Medicaid insurance only (N, %) (N=6,790).

Background:Hepatocellular carcinoma (HCC) surveillance is underutilized, with Methods:We conducted a retrospective cohort study of individuals with cirrhosis using claims data from Medicare, Medicaid, and private insurance plans in North Carolina. We included individuals ≥ 18 years with a first occurrence of an ICD-9/10 code for cirrhosis between January 1, 2010, and June 30, 2018. The outcome was HCC surveillance by abdominal ultrasound, CT, or MRI. We estimated 1- and 2-year cumulative incidences for HCC surveillance and assessed longitudinal adherence to surveillance by computing the proportion of time covered (PTC).Results:Among 46,052 individuals, 71% were enrolled through Medicare, 15% through Medicaid, and 14% through private insurance. The overall 1-year cumulative incidence of HCC surveillance was 49% and the 2-year cumulative incidence was 55%. For those with an initial screen in the first 6 months of their cirrhosis diagnosis, the median 2-year PTC was 67% (Q1, 38%; Q3, 100%).Conclusions:HCC surveillance initiation after cirrhosis diagnosis remains low, though it has improved slightly over time, particularly among individuals with Medicaid.Impact:This study provides insight into recent trends in HCC surveillance and highlights areas to target for future interventions, particularly among patients with nonviral etiologies.

Supplementary Table 4 includes descriptive statistics of the cohort, by cirrhosis etiology and by insurance type.

Supplementary Table 3 includes hypothetical examples for calculating the Proportion of Time Covered measures.

Supplementary Table S1 shows the calibration assessment in a sensitivity analysis on LASSO and Elastic-net by enforcing the adjustment of the matching factor.

Supplemental Table 1 shows univariate odds ratios, Supplemental Table 2 shows adjusted odds ratios stratified by race, and SupplementalTable 3 compares associations using mode of detection derived using a 1 year vs. 2 year interval.

Supplementary Figure S1 shows frequency of predictor inclusion in regression-based models for surveillance failure and benefit across imputed datasets.

Background:Machine learning (ML) approaches facilitate risk prediction model development using high-dimensional predictors and higher-order interactions at the cost of model interpretability and transparency. We compared the relative predictive performance of statistical and ML models to guide modeling strategy selection for surveillance mammography outcomes in women with a personal history of breast cancer (PHBC).Methods:We cross-validated seven risk prediction models for two surveillance outcomes, failure (breast cancer within 12 months of a negative surveillance mammogram) and benefit (surveillance-detected breast cancer). We included 9,447 mammograms (495 failures, 1,414 benefits, and 7,538 nonevents) from years 1996 to 2017 using a 1:4 matched case–control samples of women with PHBC in the Breast Cancer Surveillance Consortium. We assessed model performance of conventional regression, regularized regressions (LASSO and elastic-net), and ML methods (random forests and gradient boosting machines) by evaluating their calibration and, among well-calibrated models, comparing the area under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CI).Results:LASSO and elastic-net consistently provided well-calibrated predicted risks for surveillance failure and benefit. The AUCs of LASSO and elastic-net were both 0.63 (95% CI, 0.60–0.66) for surveillance failure and 0.66 (95% CI, 0.64–0.68) for surveillance benefit, the highest among well-calibrated models.Conclusions:For predicting breast cancer surveillance mammography outcomes, regularized regression outperformed other modeling approaches and balanced the trade-off between model flexibility and interpretability.Impact:Regularized regression may be preferred for developing risk prediction models in other contexts with rare outcomes, similar training sample sizes, and low-dimensional features.

Flowchart of eligibility criteria.

Supplementary Methods show the detailed information of model fitting using the machine learning approaches in this work.

Supplemental Table

Background: Insurance may lengthen or inhibit time to follow-up after positive screening mammography. We assessed the association between insurance status and time to initial diagnostic follow-up after a positive screening mammogram.Methods: Using 1995–2010 data from a North Carolina population-based registry of breast imaging and cancer outcomes, we identified women with a positive screening mammogram. We compared receipt of follow-up within 60 days of screening using logistic regression and evaluated time to follow-up initiation using Cox proportional hazards regression.Results: Among 43,026 women included in the study, 73% were Conclusions: We found differences in time to initial diagnostic follow-up after a positive screening mammogram by insurance status and age group. Uninsured women younger than 65 years at a positive screening event had delayed follow-up.Impact: Replication of these findings and examination of their clinical significance warrant additional investigation. Cancer Epidemiol Biomarkers Prev; 25(11); 1474–82. ©2016 AACR.

Background Pretreatment invasive nodal staging is paramount for appropriate treatment decisions in non-small cell lung cancer. Despite guidelines recommending when to perform staging, many studies suggest that invasive nodal staging is underutilized. Attitudes and barriers to guideline-recommended staging are unclear. The National Lung Cancer Roundtable initiated this study to better understand factors associated with guideline-adherent nodal staging. Research Question What are the knowledge gaps, attitudes, and beliefs of thoracic surgeons and pulmonologists about invasive nodal staging? What are the barriers to guideline-recommended staging? Study Design and Methods A web-based survey to a random sample of pulmonologists and thoracic surgeons identified as members of CHEST in 2019. Survey domains included knowledge of invasive nodal staging guidelines, attitudes and beliefs towards implementation, and perceived barriers to guideline adherence. Results Among 453 responding physicians, 29% were unaware that invasive nodal staging guidelines exist. Among the 320 physicians who knew guidelines exist, attitudes towards the guidelines were favorable, with 91% agreeing guidelines are generalizable and 90% agreeing that recommendations improved their staging and treatment decisions. Approximately 80% responded that guideline recommendations are based on satisfactory levels of scientific evidence, and 50% stated a lack of evidence linking adherence to guidelines to changes in management or better patient outcomes. Nearly 9 in 10 physicians reported at least one barrier to guideline adherence. The most common barriers included patient anxiety associated with treatment delays (62%), difficulty implementing guidelines into routine practice (52%), and time delays of additional testing (51%). Interpretation Among physicians who responded to our survey, more than a quarter were unaware of invasive nodal staging guidelines. Attitudes towards guideline recommendations were positive although 20% reported insufficient evidence to support staging algorithms. Most physicians reported barriers to implementing guidelines. Multi-level interventions are likely needed to increase rates of guideline-recommended invasive nodal staging.

Introduction : Understanding how incentives and their timing influence study enrollment rates is important to efficient study design and increasing the generalizability of findings. This 2-arm, parallel randomized trial evaluated how conditional versus unconditional mailed incentives of a $20 gift card affected study enrollment in a sample of participants screened for lung cancer screening. Methods : Eligible participants included Black and White adults who underwent lung cancer screening with low-dose CT and had negative screening results at two North Carolina imaging facilities in 2018. We used a stratified randomization scheme, by sex and race, to assign incentive type (conditional vs. unconditional). We used the Tailored Design Method with six points of mailed contact to engage participants. We compared study enrollment rates using chi-square tests and logistic regression analyses. Results : After adjusting for sex, race, age, smoking status, participant residence, and screening site, participants who received unconditional incentives were 74% more likely to enroll than those who received conditional incentives (adjusted OR= 1.74 (95% CI: 1.01, 3.00). Conclusions : Type of incentive can play a role in increasing study enrollment, especially mailed surveys that target individuals who currently or previously smoked. Unconditional incentives may be worth the initial cost to engage study participants.

Objective: Despite the lack of evidence that supplemental screening in women with dense breasts reduces breast cancer mortality, 38 states have passed breast density legislation, with some including recommendations for supplemental screening. The objective of this study is to compare the availability versus use of supplemental breast cancer screening modalities and determine factors driving use of supplemental screening in rural versus urban settings. Methods: A 50-item mailed survey using the Tailored Design Method was sent to American College of Radiology mammography-accredited facilities in North Carolina in 2017. Respondents included 94 facilities (48 rural and 46 urban locations). Survey questions focused on breast cancer and supplemental screening services, breast density, risk factors/assessment, and facility demographics. Results: The survey response rate was 60.3% (94/156). Among the 94 respondents, 64.0% (n = 60) reported availability of any type of supplemental screening (digital breast tomosynthesis [DBT], ultrasound, or magnetic resonance imaging [MRI]). In facilities where supplemental screening modalities were available, the most commonly utilized supplemental screening modality was DBT (96.4%), compared with ultrasound (35.7%) and MRI (46.7%). Facilities reported using supplemental screening based on patient breast density (48.3%), referring physician recommendation (63.3%), reading radiologist recommendation (63.3%), breast cancer risk factors (48.3%), and patient request (40.0%). Urban facilities were more likely than rural facilities to base supplemental screening on breast cancer risk factors (62.5% vs. 32.1%; p-value = 0.019), referring physician (75.0% vs. 50.0%; p-value = 0.045), and reading radiologist (78.1% vs. 46.4%; p-value = 0.011). Conclusion: In our study, supplemental screening modalities were widely available, with facilities more likely to use DBT for supplemental screening compared to other modalities.

BACKGROUND To understand how health care delays may affect breast cancer detection, the authors quantified changes in breast‐related preventive and diagnostic care during the coronavirus disease 2019 (COVID‐19) pandemic. METHODS Eligible women (N = 39,444) were aged ≥18 years and received a screening mammogram, diagnostic mammogram, or breast biopsy between January 1, 2019 and September 30, 2020, at 7 academic and community breast imaging facilities in North Carolina. Changes in the number of mammography or breast biopsy examinations after March 3, 2020 (the first COVID‐19 diagnosis in North Carolina) were evaluated and compared with the expected numbers based on trends between January 1, 2019 and March 2, 2020. Changes in the predicted mean monthly number of examinations were estimated using interrupted time series models. Differences in patient characteristics were tested using least squares means regression. RESULTS Fewer examinations than expected were received after the pandemic's onset. Maximum reductions occurred in March 2020 for screening mammography (−85.1%; 95% CI, −100.0%, −70.0%) and diagnostic mammography (−48.9%; 95% CI, −71.7%, −26.2%) and in May 2020 for biopsies (−40.9%; 95% CI, −57.6%, −24.3%). The deficit decreased gradually, with no significant difference between observed and expected numbers by July 2020 (diagnostic mammography) and August 2020 (screening mammography and biopsy). Several months after the pandemic's onset, women who were receiving care had higher predicted breast cancer risk (screening mammography, P < .001) and more commonly lacked insurance (diagnostic mammography, P < .001; biopsy, P < .001) compared with the prepandemic population. CONCLUSIONS Pandemic‐associated deficits in the number of breast examinations decreased over time. Utilization differed by breast cancer risk and insurance status, but not by age or race/ethnicity. Long‐term studies are needed to clarify the contribution of these trends to breast cancer disparities., In this observational study, the use of screening mammography, diagnostic mammography, and breast biopsy is significantly lower than expected after the onset of the COVID‐19 pandemic in North Carolina, but the deficits decrease over time. Health insurance status and predicted breast cancer risk are identified as predictors of mammography and biopsy receipt during the pandemic.

Background Estimating advanced breast cancer risk in women undergoing annual or biennial mammography could identify women who may benefit from less or more intensive screening. We developed an actionable model to predict cumulative 6-year advanced cancer (prognostic pathologic stage II or higher) risk according to screening interval. Methods We included 931 186 women aged 40-74 years in the Breast Cancer Surveillance Consortium undergoing 2 542 382 annual (prior mammogram within 11-18 months) or 752 049 biennial (prior within 19-30 months) screening mammograms. The prediction model includes age, race and ethnicity, body mass index, breast density, family history of breast cancer, and prior breast biopsy subdivided by menopausal status and screening interval. We used fivefold cross-validation to internally validate model performance. We defined higher than 95th percentile as high risk (>0.658%), higher than 75th percentile to 95th or less percentile as intermediate risk (0.380%-0.658%), and 75th or less percentile as low to average risk ( Results Obesity, high breast density, and proliferative disease with atypia were strongly associated with advanced cancer. The model is well calibrated and has an area under the receiver operating characteristics curve of 0.682 (95% confidence interval = 0.670 to 0.694). Based on women’s predicted advanced cancer risk under annual and biennial screening, 69.1% had low or average risk regardless of screening interval, 12.4% intermediate risk with biennial screening and average risk with annual screening, and 17.4% intermediate or high risk regardless of screening interval. Conclusion Most women have low or average advanced cancer risk and can undergo biennial screening. Intermediate-risk women may consider annual screening, and high-risk women may consider supplemental imaging in addition to annual screening.

ObjectiveWomen are increasingly informed about their breast density due to state density reporting laws. However, accuracy of personal breast density knowledge remains unclear. We compared self-reported with clinically assessed breast density and assessed knowledge of density implications and feelings about future screening.MethodsFrom December 2017 to January 2020, we surveyed women aged 40 to 74 years without prior breast cancer, with a normal screening mammogram in the prior year, and ≥1 recorded breast density measures in four Breast Cancer Surveillance Consortium registries with density reporting laws. We measured agreement between self-reported and BI-RADS breast density categorized as "ever-dense" if heterogeneously or extremely dense within the past 5 years or "never-dense" otherwise, knowledge of dense breast implications, and feelings about future screening.ResultsSurvey participation was 28% (1,528 of 5,408), and 59% (896 of 1,528) of participants had ever-dense breasts. Concordance between self-report versus clinical density was 76% (677 of 896) among women with ever-dense breasts and 14% (89 of 632) among women with never-dense breasts, and 34% (217 of 632) with never-dense breasts reported being told they had dense breasts. Desire for supplemental screening was more frequent among those who reported having dense breasts 29% (256 of 893) or asked to imagine having dense breasts 30% (152 of 513) versus those reporting nondense breasts 15% (15 of 102) (P= .003, P= .002, respectively). Women with never-dense breasts had 6.3-fold higher odds (95% confidence interval:3.39-11.80) of accurate knowledge in states reporting density to all compared to states reporting only to women with dense breasts.DiscussionStandardized communications of breast density results to all women may increase density knowledge and are needed to support informed screening decisions.

Background: Social determinants of health (SDOH) contribute to health care disparities, with social and economic barriers often leading to difficulties in obtaining necessary care. We evaluated barriers to receiving health care, focusing on caretaker responsibilities, health insurance and cost, and transportation. Materials and Methods: We included women ages ≥40 years receiving screening mammography across three Breast Cancer Surveillance Consortium registries from 2012 to 2017. Women self-reported social and financial barriers to receiving health care in the 12 months before their screening mammogram. We evaluated woman- and census-based community-level factors associated with reporting a barrier using multivariate logistic regression. We assessed interaction with urban versus nonurban residence using Wald tests. Results: Among 393,430 women, 3.6% reported a barrier with a higher proportion in urban versus nonurban settings (3.9% [n = 11,977] vs. 2.2% [n = 1,655], respectively; p

Background Supplemental breast cancer screening with breast magnetic resonance imaging (MRI) is recommended for women at high risk of breast cancer. To the authors' knowledge, recent national trends in breast MRI use are unknown. Methods The authors used claims data from a large national insurer to calculate screening breast MRI rates from 2006 to 2016 in a US cohort of 10 million women aged 20 to 64 years. Use was stratified by subgroups of women with a BRCA mutation, family history of breast cancer, and prior breast cancer history and stratified by age. Joinpoint regression evaluated annual changes in trends. Results The total sample included 37,447 screening breast MRI examinations in 25,617 women. Overall screening breast MRI rates were low and increased from 2.9 to 12.1 examinations per 10,000 women from 2006 to 2016. MRI use in women with a BRCA mutation increased by 21% on average annually from 210.8 per 10,000 women to 1562.0 per 10,000 women from 2006 to 2016. By 2016, women aged 50 to 64 years who had a BRCA mutation had the highest use of breast MRI (1669.6 MRI examinations per 10,000 women) compared with younger women (1198.4 MRI examinations per 10,000 women, 1519.1 MRI examinations per 10,000 women, and 1567.2 MRI examinations per 10,000 women, respectively, among women aged 20‐29 years, 30‐39 years, and 40‐49 years). Women with a BRCA mutation comprised

BACKGROUND. State-specific breast density notification legislation requires that women undergoing mammography be informed about breast density, with variation among states. As mammography facilities are one of the main points of contact for women undergoing mammography, research is needed to understand how facilities communicate information on breast density, cancer risk, and supplemental screening with women. METHODS. A cross-sectional 50-item mailed survey was conducted with 156 American College of Radiology certified mammography facilities in North Carolina in 2017 using the Tailored Design Method. Breast density notification practices, supplemental screening services, and patient educational materials were compared by supplemental screening availability using t-tests and chi-square tests. RESULTS. All responding facilities (n=94; 60.3% response rate) notified women of their breast density in the mammography result letter. Breast cancer risk assessments were performed by 36.3% of facilities, with risk information communicated in the final radiology report for the referring provider to discuss with the woman (79.4%) or in the result letter (58.8%). Supplemental breast cancer screening was offered by 63.8% of facilities, with use based on multiple factors including recommendations from the referring physician (63.3%) or reading radiologist (63.3%), breast density (48.3%), other risk factors (48.3%), and woman request (40.0%). While 75% of facilities offered breast density educational materials, only 36.6% offered educational materials on supplemental screening. CONCLUSION. In a state with a breast density notification law, mammography facilities communicate breast density, cancer risk, and supplemental screening information to women using various approaches. When supplemental screening is offered, facilities utilize multiple decision-making criteria, rather than breast density alone. PRECIS. In a state with breast density notification, mammography facilities communicate breast density, cancer risk, and supplemental screening information to women using various approaches. When supplemental screening is offered, facilities utilize multiple decision-making criteria, rather than breast density alone.

Rationale and Objectives Resident journal clubs are essential to develop skills to critically appraise existing literature. However, most reports of journal clubs focus on logistics of the activity and less on established roles of those involved. Our objective is to report on an innovative journal club from the perspective of key participants. Materials and Methods Journal club schedule, assignments, evaluations, and analysis are proffered from our institution. The journal club goals were formulated as: (1) improving resident understanding of research (biostatistical and epidemiologic) methods and statistical concepts, (2) teaching critical appraisal skills, and (3) promoting the use of evidence-based medicine. Each session's format is interactive, consisting of a 10 minute lecture with radiology examples of a research or statistical concept, followed by a journal club style discussion. Crucial to the success of this curriculum has been input and engagement of multiple parties: radiology residents, epidemiologist directors, and subspecialist clinician educator faculty members. Conclusion A well-thought out and well-run resident journal club offers numerous solutions to radiology residencies. To residency program leadership and to each individual resident annually, resident journal club offers cutting edge medical knowledge, interactive conferences in the formal didactic curriculum, resident training in critical thinking skills and research design, resident training in interpersonal and communication skills, opportunity for residents to be teachers, and expanded resident interprofessional education. It meets Accreditation Council for Graduate Medical Education common program, Residency Review Committee diagnostic radiology program, and American Board of Radiology Milestones requirements.

We evaluated self-report of decision quality and regret with breast cancer surgical treatment by pre-operative breast MRI use in women recently diagnosed with breast cancer.We conducted a survey with 957 women aged 18 + with stage 0-III breast cancer identified in the Breast Cancer Surveillance Consortium. Participants self-reported receipt of pre-operative breast MRI. Primary outcomes were process measures in the Breast Cancer Surgery Decision Quality Instrument (BCS-DQI) (continuous outcome) and Decision Regret Scale (dichotomized outcome as any/none). Generalized estimating equations with linear and logit link were used to estimate adjusted associations between breast MRI and primary outcomes. All analyses were also stratified by breast density.Survey participation rate was 27.9% (957/3430). Study population was primarily 60 years, White, college educated, and diagnosed with early-stage breast cancer. Pre-operative breast MRI was reported in 46% of women. A higher proportion of women who were younger age ( 50 years), commercially insured, and self-detected their breast cancer reported pre-operative breast MRI use. In adjusted analysis, pre-operative breast MRI use compared with no use was associated with a small but statistically significantly higher decision quality scores (69.5 vs 64.7, p-value = 0.043). Decision regret did not significantly differ in women who reported pre-operative breast MRI use compared with no use (54.2% v. 48.7%, respectively, p-value = 0.11). Study results did not vary when stratified by breast density for either primary outcome.Breast MRI use in the diagnostic work-up of breast cancer does not negatively alter women's perceptions of surgical treatment decisions in early survivorship.NCT03029286.

Background: We evaluated differences in diagnostic mammography performance based on women's race/ethnicity. Methods: This cohort study included 267,868 diagnostic mammograms performed to evaluate screening mammogram findings at 98 facilities in the Breast Cancer Surveillance Consortium between 2005 and 2017. Mammogram assessments were recorded prospectively and breast cancers occurring within one year were ascertained. Performance statistics were calculated with 95% confidence intervals (CI) for each racial/ethnic group. Multivariable regression was used to control for personal characteristics and imaging facility. Results: Among non-Hispanic White (70%), non-Hispanic Black (13%), Asian/Pacific Islander (10%), and Hispanic (7%) women, the invasive cancer detection rate (iCDR, per 1,000 mammograms) and positive predictive value (PPV2) were highest among non-Hispanic White women (iCDR, 35.8; 95% CI, 35.0–36.7; PPV2, 27.8; 95% CI, 27.3–28.3) and lowest among Hispanic women (iCDR, 22.3; 95% CI, 20.2–24.6; PPV2, 19.4; 95% CI, 18.0–20.9). Short interval follow-up recommendations were most common among non-Hispanic Black women [(31.0%; 95% CI, 30.6%–31.5%) vs. other groups, range, 16.6%–23.6%]. False-positive biopsy recommendations were most common among Asian/Pacific Islander women [per 1,000 mammograms: 169.2; 95% CI, 164.8–173.7) vs. other groups, range, 126.5–136.1]. Some differences were explained by adjusting for receipt of diagnostic ultrasound or MRI for iCDR and imaging facility for short-interval follow-up. Other differences changed little after adjustment. Conclusions: Diagnostic mammography performance varied across racial/ethnic groups. Addressing characteristics related to imaging facility and access, rather than personal characteristics, may help reduce some of these disparities. Impact: Diagnostic mammography performance studies should include racially and ethnically diverse populations to provide an accurate view of the population-level effects.

BACKGROUND The cost-effectiveness of screening mammography beyond age 75 years remains unclear. OBJECTIVE To estimate benefits, harms, and cost-effectiveness of extending mammography to age 80, 85, or 90 years according to comorbidity burden. DESIGN Markov microsimulation model. DATA SOURCES SEER (Surveillance, Epidemiology, and End Results) program and Breast Cancer Surveillance Consortium. TARGET POPULATION U.S. women aged 65 to 90 years in groups defined by Charlson comorbidity score (CCS). TIME HORIZON Lifetime. PERSPECTIVE National health payer. INTERVENTION Screening mammography to age 75, 80, 85, or 90 years. OUTCOME MEASURES Breast cancer death, survival, and costs. RESULTS OF BASE-CASE ANALYSIS Extending biennial mammography from age 75 to 80 years averted 1.7, 1.4, and 1.0 breast cancer deaths and increased days of life gained by 5.8, 4.2, and 2.7 days per 1000 women for comorbidity scores of 0, 1, and 2, respectively. Annual mammography beyond age 75 years was not cost-effective, but extending biennial mammography to age 80 years was ($54 000, $65 000, and $85 000 per quality-adjusted life-year [QALY] gained for women with CCSs of 0, 1, and ≥2, respectively). Overdiagnosis cases were double the number of deaths averted from breast cancer. RESULTS OF SENSITIVITY ANALYSIS Costs per QALY gained were sensitive to changes in invasive cancer incidence and shift of breast cancer stage with screening mammography. LIMITATION No randomized controlled trials of screening mammography beyond age 75 years are available to provide model parameter inputs. CONCLUSION Although annual mammography is not cost-effective, biennial screening mammography to age 80 years is; however, the absolute number of deaths averted is small, especially for women with comorbidities. Women considering screening beyond age 75 years should weigh the potential harms of overdiagnosis versus the potential benefit of averting death from breast cancer. PRIMARY FUNDING SOURCE National Cancer Institute and National Institutes of Health.

Background The COVID-19 pandemic reduced mammography use, potentially delaying breast cancer diagnoses. Purpose To examine breast biopsy recommendations and breast cancers diagnosed before and during the COVID-19 pandemic by mode of detection (screen detected vs symptomatic) and women's characteristics. Materials and Methods In this secondary analysis of prospectively collected data, monthly breast biopsy recommendations after mammography, US, or both with subsequent biopsy performed were examined from 66 facilities of the Breast Cancer Surveillance Consortium between January 2019 and September 2020. The number of monthly and cumulative biopsies recommended and performed and the number of subsequent cancers diagnosed during the pandemic period (March 2020 to September 2020) were compared with data from the prepandemic period using Wald χ2 tests. Analyses were stratified by mode of detection and race or ethnicity. Results From January 2019 to September 2020, 17 728 biopsies were recommended and performed, with 6009 cancers diagnosed. From March to September 2020, there were substantially fewer breast biopsy recommendations with cancer diagnoses when compared with the same period in 2019 (1650 recommendations in 2020 vs 2171 recommendations in 2019 [24% fewer], P < .001), predominantly due to fewer screen-detected cancers (722 cancers in 2020 vs 1169 cancers in 2019 [38% fewer], P < .001) versus symptomatic cancers (895 cancers in 2020 vs 965 cancers in 2019 [7% fewer], P = .27). The decrease in cancer diagnoses was largest in Asian (67 diagnoses in 2020 vs 142 diagnoses in 2019 [53% fewer], P = .06) and Hispanic (82 diagnoses in 2020 vs 145 diagnoses in 2019 [43% fewer], P = .13) women, followed by Black women (210 diagnoses in 2020 vs 287 diagnoses in 2019 [27% fewer], P = .21). The decrease was smallest in non-Hispanic White women (1128 diagnoses in 2020 vs 1357 diagnoses in 2019 [17% fewer], P = .09). Conclusion There were substantially fewer breast biopsies with cancer diagnoses during the COVID-19 pandemic from March to September 2020 compared with the same period in 2019, with Asian and Hispanic women experiencing the largest declines, followed by Black women. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Heller in this issue.

ImportanceMaximizing benefits of lung cancer screening requires timely follow-up after a positive screening test. The American College of Radiology (ACR) Lung CT Screening Reporting and Data System (Lung-RADS) recommends testing and follow-up timing based on the screening result.ObjectiveTo determine rates of and factors associated with recommended follow-up after a positive lung cancer screening examination by Lung-RADS category.Design, Setting, and ParticipantsThis prospective cohort study of lung cancer screening examinations performed from January 1, 2015, through July 31, 2020, with follow-up through July 31, 2021, was conducted at 5 academic and community lung cancer screening sites in North Carolina. Participants included 685 adults with a positive screening examination, Lung-RADS categories 3, 4A, 4B, or 4X. Statistical analysis was performed from December 2020 to March 2022.ExposuresIndividual age, race, sex, smoking exposure, year of lung cancer screening examination, chronic obstructive pulmonary disease, body mass index, referring clinician specialty, rural or urban residence.Main Outcomes and MeasuresAdherence, defined as receipt of recommended follow-up test or procedure after the positive screen per ACR Lung-RADS timeframes: 6 months for Lung-RADS 3 and 3 months for Lung-RADS 4A. For Lung-RADS 4B or 4X, adherence was defined as follow-up care within 4 weeks, as ACR Lung-RADS does not specify a timeframe.ResultsAmong the 685 individuals included in this study who underwent lung cancer screening with low-dose computed tomography, 416 (60.7%) were aged at least 65 years, 123 (18.0%) were Black, 562 (82.0%) were White, and 352 (51.4%) were male. Overall adherence to recommended follow-up was 42.6% (292 of 685) and varied by Lung-RADS category: Lung-RADS 3 = 30.0% (109 of 363), Lung-RADS 4A = 49.5% (96 of 194), Lung-RADS 4B or 4X = 68.0% (87 of 128). Extending the follow-up time increased adherence: Lung-RADS 3 = 68.6% (249 of 363) within 9 months, Lung-RADS 4A = 77.3% (150 of 194) within 5 months, and Lung-RADS 4B or 4X = 80.5% (103 of 128) within 62 days. For Lung-RADS 3, recommended follow-up was less likely among those currently smoking vs those who quit (adjusted odds ratio [aOR], 0.48; 95% CI, 0.29-0.78). In Lung-RADS 4A, recommended follow-up was less likely in Black individuals vs White individuals (aOR, 0.35; 95% CI, 0.15-0.86). For Lung-RADS 4B or 4X, recommended follow-up was more likely in female individuals vs male individuals (aOR, 2.82; 95% CI, 1.09-7.28) and less likely in those currently smoking vs those who quit (aOR, 0.31; 95% CI, 0.12-0.80).Conclusions and RelevanceIn this cohort study, adherence to recommended follow-up after a positive screening examination was low but improved among nodules with a higher suspicion of cancer and after extending the follow-up timeline. However, the association of extending the follow-up time of screen-detected nodules with outcomes at the population level, outside of a clinical trial, is unknown. These findings suggest that studies to understand why recommended follow-up is lower in Black individuals, male individuals, and individuals currently smoking are needed to develop strategies to improve adherence.

Comorbidities characterize the underlying health status of individuals. In the context of lung cancer screening (LCS), lung-related comorbidities may influence the observed benefits and harms.To compare the characteristics of individuals undergoing LCS, the LCS examination result, the cancer detection rate (CDR), and the false-positive rate (FPR) in those with and without lung-related comorbidities.A prospective cohort study was conducted in 5 academic and community screening sites across North Carolina from January 1, 2014, to November 7, 2020. Participants included 611 individuals screened for lung cancer who completed a 1-page health history questionnaire.Presence of at least 1 self-reported lung-related comorbidity, including chronic obstructive pulmonary disease, chronic bronchitis, emphysema, asthma, bronchiectasis, pulmonary fibrosis, silicosis, asbestosis, sarcoidosis, and tuberculosis.The LCS examination result was determined from the radiologist's Lung Imaging Reporting and Data System assessment (negative, 1 or 2; positive, 3 or 4). The age-adjusted CDR and FPR were calculated per 100 LCS examinations, using binary logistic regression.Among the 611 individuals screened for lung cancer (308 men [50.4%]; mean [SD] age, 64 [6.2] years), 335 (54.8%) had at least 1 lung-related comorbidity. Individuals with vs without lung-related comorbidities were more likely to be female than male (180 of 335 [53.7%] vs 123 of 276 [44.6%]; P = .02), White vs non-White race (275 of 326 [84.4%] vs 193 of 272 [71.0%]; P .001), and have high school or less education vs greater than a high school education (108 of 231 [46.7%] vs 64 of 208 [30.8%]; P = .001). There were no significant differences in the proportion of positive LCS examinations in those with vs without a lung-related comorbidity at baseline (37 [16.0%] vs 22 [11.1%]; P = .14) or subsequent (40 [12.3%] vs 23 [10.6%]; P = .54) LCS examination. Comparing individuals with vs without lung-related comorbidities, there was no statistically significant difference in the CDR (1.6 vs 1.9 per 100; P = .73) or FPR (13.0 vs 9.3 per 100; P = .16). Of the 17 individuals with lung cancer, 13 patients (76.5%) were diagnosed with stage I lung cancer.The findings of this study suggest that individuals with self-reported lung-related comorbidities undergoing LCS were more likely to be female, of White race, and have less education than those without lung-related comorbidity. Although no statistically significant differences in the proportion of positive examinations, CDR, or FPR by self-reported lung comorbidities were noted, additional studies with larger numbers of individuals undergoing screening are needed to understand LCS outcomes in those with lung-related comorbidities.

PURPOSE Preoperative breast MRI is used to evaluate for additional cancer and extent of disease for newly diagnosed breast cancer, yet benefits and harms of preoperative MRI are not well-documented. We examined whether preoperative MRI yields additional biopsy and cancer detection by extent of breast density. METHODS We followed women in the Breast Cancer Surveillance Consortium with an incident breast cancer diagnosed from 2005 to 2017. We quantified breast biopsies and cancers detected within 6 months of diagnosis by preoperative breast MRI receipt, overall and by breast density, accounting for MRI selection bias using inverse probability weighted logistic regression. RESULTS Among 19,324 women with newly diagnosed breast cancer, 28% had preoperative MRI, 11% additional biopsy, and 5% additional cancer detected. Four times as many women with preoperative MRI underwent additional biopsy compared to women without MRI (22.6% v. 5.1%). Additional biopsy rates with preoperative MRI increased with increasing breast density (27.4% for extremely dense compared to 16.2% for almost entirely fatty breasts). Rates of additional cancer detection were almost four times higher for women with v. without MRI (9.9% v. 2.6%). Conditional on additional biopsy, age-adjusted rates of additional cancer detection were lowest among women with extremely dense breasts, regardless of imaging modality (with MRI: 35.0%; 95% CI 27.0-43.0%; without MRI: 45.1%; 95% CI 32.6-57.5%). CONCLUSION For women with dense breasts, preoperative MRI was associated with much higher biopsy rates, without concomitant higher cancer detection. Preoperative MRI may be considered for some women, but selecting women based on breast density is not supported by evidence. TRIAL REGISTRATION ClinicalTrials.gov: NCT02980848; registered 2017.

INTRODUCTION: Limited evidence exists on the impact of age and comorbidity on biopsy rates and findings among older women. MATERIALS AND METHODS: We used data from 170,657 women ages 66–94 enrolled in the United States Breast Cancer Surveillance Consortium (BCSC). We estimated one-year rates of biopsy by type (any, fine-needle aspiration (FNA), core or surgical) and yield of the most invasive biopsy finding (benign, ductal carcinoma in situ (DCIS) and invasive breast cancer) by age and comorbidity. Statistical significance was assessed using Wald statistics comparing coefficients estimated from logistic regression models adjusted for age, comorbidity, BCSC registry, and interaction between age and comorbidity. RESULTS: Of 524,860 screening mammograms, 9830 biopsies were performed following 7930 exams (1.5%) within one year, specifically 5589 core biopsies (1.1%), 3422 (0.7%) surgical biopsies and 819 FNAs (0.2%). Biopsy rates per 1000 screens decreased with age (66–74:15.7, 95%CI:14.8–16.8), 75–84:14.5(13.5–15.6), 85–94:13.2(11.3,15.4), p(trend)=2:19.0 (16.9–21.5), p(trend)

BACKGROUND: Pretreatment invasive nodal staging is paramount for appropriate treatment decisions in non-small cell lung cancer. Despite guidelines recommending when to perform staging, many studies suggest that invasive nodal staging is underused. Attitudes and barriers to guideline-recommended staging are unclear. The National Lung Cancer Roundtable initiated this study to better understand the factors associated with guideline-adherent nodal staging. RESEARCH QUESTION: What are the knowledge gaps, attitudes, and beliefs of thoracic surgeons and pulmonologists about invasive nodal staging? What are the barriers to guideline-recommended staging? STUDY DESIGN AND METHODS: A web-based survey of a random sample of pulmonologists and thoracic surgeons identified as members of American College of Chest Physicians (CHEST) was conducted in 2019. Survey domains included knowledge of invasive nodal staging guidelines, attitudes and beliefs toward implementation, and perceived barriers to guideline adherence. RESULTS: Among 453 responding physicians, 29% were unaware that invasive nodal staging guidelines exist. Among the 320 physicians who knew guidelines exist, attitudes toward the guidelines were favorable, with 91% agreeing guidelines are generalizable and 90% agreeing that recommendations improved their staging and treatment decisions. Approximately 80% responded that guideline recommendations are based on satisfactory levels of scientific evidence, and 50% stated a lack of evidence linking adherence to guidelines to changes in management or better patient outcomes. Nearly 9 in 10 physicians reported at least one barrier to guideline adherence. The most common barriers included patient anxiety associated with treatment delays (62%), difficulty implementing guidelines into routine practice (52%), and time delays of additional testing (51%). INTERPRETATION: Among physicians who responded to our survey, more than one-quarter were unaware of invasive nodal staging guidelines. Attitudes toward guideline recommendations were positive, although 20% reported insufficient evidence to support staging algorithms. Most physicians reported barriers to implementing guidelines. Multilevel interventions are likely needed to increase rates of guideline-recommended invasive nodal staging.

Background: Previous reports suggested risk of death and breast cancer varied by comorbidity and age in older women undergoing mammography. However, impacts of functional limitations remain unclear. Methods: We used data from 238,849 women in the Breast Cancer Surveillance Consortium-Medicare linked database (1999–2015) who had screening mammogram at ages 66–94 years. We estimated risk of breast cancer, breast cancer death, and non-breast cancer death by function-related indicator (FRI) which incorporated 16 claims-based items and was categorized as an ordinal variable (0, 1, and 2+). Fine and Gray proportional sub-distribution hazards models were applied with breast cancer and death treated as competing events. Risk estimates by FRI scores were adjusted by age and NCI comorbidity index separately and stratified by these factors. Results: Overall, 9,252 women were diagnosed with breast cancer, 406 died of breast cancer, and 41,640 died from non-breast cancer causes. The 10-year age-adjusted invasive breast cancer risk slightly decreased with FRI score [FRI = 0: 4.0%, 95% confidence interval (CI) = 3.8–4.1; FRI = 1: 3.9%, 95% CI = 3.7–4.2; FRI ≥ 2: 3.5%, 95% CI = 3.1–3.9). Risk of non-breast cancer death increased with FRI score (FRI = 0: 18.8%, 95% CI = 18.5–19.1; FRI = 1: 24.4%, 95% CI = 23.9–25.0; FRI ≥ 2: 39.8%, 95% CI = 38.8–40.9]. Risk of breast cancer death was low with minimal differences across FRI scores. NCI comorbidity index–adjusted models and stratified analyses yielded similar patterns. Conclusions: Risk of non-breast cancer death substantially increases with FRI score, whereas risk of breast cancer death is low regardless of functional status. Impact: Older women with functional limitations should be informed that they may not benefit from screening mammography.

The National Lung Screening Trial (NLST) showed a 20% relative reduction in lung cancer mortality among current and former (quit within the last 15 years) smokers aged 55–74 years with at least a 30 pack-year smoking history who underwent lung cancer screening (LCS) with low dose computed tomography (LDCT) versus chest radiography (1).

ImportanceDiagnostic delays in breast cancer detection may be associated with later-stage disease and higher anxiety, but data on multilevel factors associated with diagnostic delay are limited.ObjectiveTo evaluate individual-, neighborhood-, and health care–level factors associated with differences in time from abnormal screening to biopsy among racial and ethnic groups.Design, Setting, and ParticipantsThis prospective cohort study used data from women aged 40 to 79 years who had abnormal results in screening mammograms conducted in 109 imaging facilities across 6 US states between 2009 and 2019. Data were analyzed from February 21 to November 4, 2021.ExposuresIndividual-level factors included self-reported race and ethnicity, age, family history of breast cancer, breast density, previous breast biopsy, and time since last mammogram; neighborhood-level factors included geocoded education and income based on residential zip codes and rurality; and health care–level factors included mammogram modality, screening facility academic affiliation, and facility onsite biopsy service availability. Data were also assessed by examination year.Main Outcome and MeasuresThe main outcome was unadjusted and adjusted relative risk (RR) of no biopsy within 30, 60, and 90 days using sequential log-binomial regression models. A secondary outcome was unadjusted and adjusted median time to biopsy using accelerated failure time models.ResultsA total of 45 186 women (median [IQR] age at screening, 56 [48-65] years) with 46 185 screening mammograms with abnormal results were included. Of screening mammograms with abnormal results recommended for biopsy, 15 969 (34.6%) were not resolved within 30 days, 7493 (16.2%) were not resolved within 60 days, and 5634 (12.2%) were not resolved within 90 days. Compared with White women, there was increased risk of no biopsy within 30 and 60 days for Asian (30 days: RR, 1.66; 95% CI, 1.31-2.10; 60 days: RR, 1.58; 95% CI, 1.15-2.18), Black (30 days: RR, 1.52; 95% CI, 1.30-1.78; 60 days: 1.39; 95% CI, 1.22-1.60), and Hispanic (30 days: RR, 1.50; 95% CI, 1.24-1.81; 60 days: 1.38; 95% CI, 1.11-1.71) women; however, the unadjusted risk of no biopsy within 90 days only persisted significantly for Black women (RR, 1.28; 95% CI, 1.11-1.47). Sequential adjustment for selected individual-, neighborhood-, and health care–level factors, exclusive of screening facility, did not substantially change the risk of no biopsy within 90 days for Black women (RR, 1.27; 95% CI, 1.12-1.44). After additionally adjusting for screening facility, the increased risk for Black women persisted but showed a modest decrease (RR, 1.20; 95% CI, 1.08-1.34).Conclusions and RelevanceIn this cohort study involving a diverse cohort of US women recommended for biopsy after abnormal results on screening mammography, Black women were the most likely to experience delays to diagnostic resolution after adjusting for multilevel factors. These results suggest that adjustment for multilevel factors did not entirely account for differences in time to breast biopsy, but unmeasured factors, such as systemic racism and other health care system factors, may impact timely diagnosis.