Anne C. Hoyt

Negative Predictive Value of Sonography and Mammography in Patients with Focal Breast Pain

Abstract:  The purpose of this study was to determine the negative predictive value of mammography and sonography in a population of patients with focal breast pain referred for imaging evaluation. Eighty‐six consecutive patients with focal breast pain in the absence of a breast mass were retrospectively identified from an imaging database. The electronic inpatient and outpatient records for the 86 patients were reviewed. For patients who were diagnosed with breast cancer, pathology reports were reviewed to determine whether the painful area corresponded to the patients cancer. In addition, patient records were linked to the institutions cancer registry. Of the 86 patients, 26 patients were lost to follow‐up and did not appear in the institutions cancer registry. Four patients were diagnosed with breast carcinoma, two of whom had incidental cancers that were detected mammographically by microcalcifications and were separate from and unrelated to the area of pain. Seven patients underwent biopsy at the site of breast pain with benign diagnosis. Imaging and clinical follow‐up for the 51 patients with benign or negative imaging at the site of pain showed no abnormality with a mean follow‐up of 26.5 months. The negative predictive value of mammography and sonography in patients with breast pain was 100%. The negative predictive value of mammography and sonography for focal breast pain is high. Negative mammography and sonography can be reassuring to the treating clinician if follow‐up is planned when physical examination is not suspicious. However, if physical examination is suspicious, biopsy should not be delayed. 

Mammographic Signs of Systemic Disease

Although mammography is primarily used for the detection of breast cancer, it can occasionally reveal breast abnormalities related to extramammary disease. Cardiovascular diseases such as congestive heart failure and central venous obstruction may manifest as venous engorgement and breast edema at mammography. Pathologic arterial calcifications seen at mammography can indicate an underlying risk factor for accelerated atherosclerosis such as chronic renal failure. Connective tissue diseases including rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis-polymyositis, and systemic scleroderma typically manifest with bilateral axillary lymphadenopathy, and stromal calcifications are also seen in the latter three disease processes. Some diseases such as neurofibromatosis type 1 and filariasis may manifest with pathognomonic findings at mammography, whereas other systemic diseases such as Wegener granulomatosis, sarcoidosis, and amyloidosis can manifest as nonspecific breast masses that are indistinguishable from breast cancer and usually require tissue biopsy for confirmation. Knowledge of the imaging characteristics of various systemic diseases affecting the breast will aid the radiologist in differentiating systemic disease from suspect breast lesions, thereby helping ensure appropriate follow-up. Furthermore, recognition of systemic diseases such as Cowden syndrome that are associated with an increased risk of breast cancer will allow the radiologist to recommend appropriate surveillance.

Digital mammography: clinical image evaluation.

This article addresses the essential components of the clinical image evaluation process for mammography examinations. The American College of Radiology Mammography Accreditation Program has specified 8 categories of image evaluation that are addressed in this article. While focused on the 2-view screening examination, the same general principles should apply to diagnostic mammograms. This article specifically focuses on the clinical image evaluation process as it applies to digital mammography.

Multidisciplinary breast clinic: Impact on patient satisfaction, timeliness, and guideline concordant care.

124 Background: After recent implementation of a multidisciplinary breast clinic (MDC) for newly diagnosed women at our institution, we sought to examine the impact of MDC on patient satisfaction, timeliness and guideline concordant care. METHODS Women with newly diagnosed breast cancer at our institution are referred to MDC where they are seen by a team of breast specialists for initial consultation. The MDC model is further facilitated by a patient navigator/coordinator who serves as a single point of contact across disciplines and through the continuum of care. We deployed patient satisfaction surveys querying helpfulness of the care coordinator and satisfaction with seeing breast cancer specialty physicians together in one visit. We further retrospectively analyzed timeliness of care and guideline concordant care since MDC implementation. RESULTS Patient satisfaction survey response rate was 42% (n=133).On a scale of 1 (very poor) - 5 (excellent), 93% of respondents rated helpfulness of care coordinator as excellent and seeing specialty physicians together in one visit as excellent. 99% of respondents rated these factors as either excellent (5) or good (4). Regarding timeliness, among 202 women with newly diagnosed, non-metastatic breast cancer seen in MDC between June 2012 and April 2014, mean time from neoadjuvant chemotherapy to surgery was 43.1 days (range 26-78 days), from surgery to adjuvant radiation was 39.2 days (range 22-79 days), from surgery to adjuvant chemotherapy was 40.6 days (range 19-89 days), and from adjuvant chemotherapy to radiation was 34.9 days (range 13-67 days). All timeliness metrics well exceeded established national standards of 60-90 days. Regarding guideline concordant care, 94% and 90% respectively received indicated radiation therapy and chemotherapy in accordance with National Comprehensive Cancer Network (NCCN) Guidelines. Those not receiving guideline concordant care either declined, were of advanced age, or had prohibitive co-morbidities. CONCLUSIONS The MDC model, which emphasizes care coordination via a team approach and patient navigation, is associated with excellent patient satisfaction and timely, guideline concordant breast cancer care.

Role of Clinical and Imaging Risk Factors in Predicting Breast Cancer Diagnosis among BI-RADS 4 Cases

Micro‐Abstract Overdiagnosis of breast cancer is an ongoing concern, particularly in women who receive a Breast Imaging Reporting and Data System (BI‐RADS) 4 assessment. Using a population‐based quality improvement registry of 1978 women (2138 examinations), we examined clinical and imaging risk factors using cross‐validated logistic regression models, identifying significant predictors such as age, the presence of a lump, history of breast cancer, the number of high‐risk triggers, BI‐RADS score, and qualitative breast density. This analysis supports the potential added value of utilizing relevant information from the patients medical history when deciding between active surveillance and biopsy. Purpose: To analyze women with suspicious findings (assessed as Breast Imaging Reporting and Data System [BI‐RADS] 4), examining the value of clinical and imaging predictors in predicting cancer diagnosis. Patients and Methods: A set of 2138 examinations (1978 women) given a BI‐RADS 4 with matching pathology results were analyzed. Predictors such as patient demographics, clinical risk factors, and imaging‐derived features such as BI‐RADS assessment and qualitative breast density were considered. Independent predictors of breast cancer were determined by univariate analysis and multivariate logistic regression. Results: In univariate analysis, age, race, body mass index, age at first live birth, BI‐RADS assessment, qualitative breast density, and risk triggers were found to be independent predictors. In multivariate analysis, age, BI‐RADS score, breast density, race, presence of a lump, and number of risk triggers were the most predictive. An integrative logistic regression model achieved a performance of 0.84 cross‐validated area under the curve. No variable was a constant independent predictor when stratifying the population on the basis of the BI‐RADS score. Conclusion: While BI‐RADS assessment remains the strongest predictor of breast cancer, the inclusion of clinical risk factors such as age, breast density, presence of a lump, and number of risk triggers derived from guidelines improves the specificity of identifying individuals with imaging descriptors associated with BI‐RADS 4A and 4B that are more likely to be diagnosed with breast cancer.

Assessing the Effect of Lifetime Contralateral Breast Cancer Risk on the Selection of Contralateral Prophylactic Mastectomy for Unilateral Breast Cancer

Introduction: Contralateral prophylactic mastectomy (CPM) rates are rising, with fear implicated as a contributing factor. This study used a contralateral breast cancer (CBC) risk stratification tool to assess whether the selection of CPM is reflective of future CBC risk. Patients and Methods: This retrospective study evaluated 404 women with unilateral breast cancer treated with breast conservation, unilateral mastectomy, or bilateral mastectomy within a single multidisciplinary clinic. Women were evaluated by the Manchester risk tool to calculate lifetime CBC risk. Logistic regression analysis was used to evaluate whether CBC risk was associated with CPM, and the clinical rationale for prophylactic mastectomy justification was recorded. Results: Sixty‐two percent underwent breast conservation, 18% unilateral mastectomy, and 20% bilateral mastectomy. In the CPM cohort, 36% had > 20% calculated lifetime CBC risk. In the invasive cohort, younger age (odds ratio 2.65, P < .0001) and genetic mutation positivity (odds ratio 35.39, P = .019) independently predicted CPM. Other contributing factors included benign contralateral breast findings (29%) and recommendations against breast conservation due to disease burden (28%). Six percent selected CPM as a result of an unsubstantiated fear regarding breast cancer. Conclusion: The majority of women (63%) who selected CPM had < 20% CBC risk. In these lower‐risk women selecting CPM, factors increasing reasonable fear dominated surgical choice (81% of this subset).

Rates of appropriate genetic testing referral for breast cancer patients treated in a multidisciplinary cancer care setting.

45 Background: Approximately 5% to 10% of women diagnosed with breast cancer have a genetic predisposition, which can affect management recommendations. The National Comprehensive Cancer Network (NCCN) has established guidelines for genetics referral and testing, however recent publications have indicated low rates of family history documentation and appropriate genetics referral. We sought to assess the impact of standardized family history documentation on rates of appropriate genetics referral in a multidisciplinary breast clinic (MDC) setting. METHODS In advance of MDC consultation, women with newly diagnosed breast cancer complete an intake questionnaire which includes documentation of Ashkenazi Jewish ancestry along with a thorough family history. We retrospectively analyzed family history documentation to inform eligibility for genetic testing and rates of appropriate genetics referral. RESULTS Between June 2012 and April 2014, 202 women with newly diagnosed, nonmetastatic breast cancer were seen in MDC. We noted 100% compliance with family history documentation. Per NCCN Guidelines, genetic testing was indicated in 52% (106 patients), of which 77% were appropriately referred to a genetic counselor for evaluation. All patients who met criteria based on personal history factors including age ≤ 45, triple-negative disease under age 60, or two or more breast primaries under age 50 were appropriately referred. Patients who were eligible but not referred ranged in age from 46 to 93 and were eligible for testing based on Ashkenzi Jewish ancestry (3 patients) or family history factors including a relative with ovarian cancer (3 patients), ≥2 relatives with breast cancer (5 patients), or a relative with breast cancer < age 50 (7 patients). CONCLUSIONS Compared with recently published national averages, rates of appropriate family history documentation and genetic testing referrals are significantly higher in our MDC setting. However, this analysis has identified significant opportunity for improvement via identification of overlooked referral indications. Initiatives are underway to improve future compliance.

False-Negative Mammograms: Causes and Solutions

A mammogram is defined as false-negative when there is a diagnosis of breast cancer within 1 year of a mammogram that had been interpreted as negative (BI-RADS® 1, 2, or 3). False-negative mammograms have significant medicolegal implications. According to the Physician Insurers Association of America (PIAA), delayed diagnosis of breast cancer is the leading cause of malpractice claims, and radiologists are the most frequent defendants. Of these claims, 80% of the women had false-negative mammograms. The average payment in 2002 was

Factors Associated With MRI Screening in Women With a Personal History of Invasive, Unilateral Breast Cancer Predominately Encompass Detectability Concerns Rather Than Future Breast Cancer Risk

346,247. In a recent survey, fear of missing a breast cancer and lawsuits were two of the leading reasons that residents did not want to interpret mammograms.1 This article reviews some of the causes of false-negative mammograms and possible ways to avoid these pitfalls.