Sarah M. Friedewald

Breast Cancer Screening Using Tomosynthesis in Combination With Digital Mammography

IMPORTANCE Mammography plays a key role in early breast cancer detection. Single-institution studies have shown that adding tomosynthesis to mammography increases cancer detection and reduces false-positive results. OBJECTIVE To determine if mammography combined with tomosynthesis is associated with better performance of breast screening programs in the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of screening performance metrics from 13 academic and nonacademic breast centers using mixed models adjusting for site as a random effect. EXPOSURES Period 1: digital mammography screening examinations 1 year before tomosynthesis implementation (start dates ranged from March 2010 to October 2011 through the date of tomosynthesis implementation); period 2: digital mammography plus tomosynthesis examinations from initiation of tomosynthesis screening (March 2011 to October 2012) through December 31, 2012. MAIN OUTCOMES AND MEASURES Recall rate for additional imaging, cancer detection rate, and positive predictive values for recall and for biopsy. RESULTS A total of 454,850 examinations (n=281,187 digital mammography; n=173,663 digital mammography + tomosynthesis) were evaluated. With digital mammography, 29,726 patients were recalled and 5056 biopsies resulted in cancer diagnosis in 1207 patients (n=815 invasive; n=392 in situ). With digital mammography + tomosynthesis, 15,541 patients were recalled and 3285 biopsies resulted in cancer diagnosis in 950 patients (n=707 invasive; n=243 in situ). Model-adjusted rates per 1000 screens were as follows: for recall rate, 107 (95% CI, 89-124) with digital mammography vs 91 (95% CI, 73-108) with digital mammography + tomosynthesis; difference, -16 (95% CI, -18 to -14; P < .001); for biopsies, 18.1 (95% CI, 15.4-20.8) with digital mammography vs 19.3 (95% CI, 16.6-22.1) with digital mammography + tomosynthesis; difference, 1.3 (95% CI, 0.4-2.1; P = .004); for cancer detection, 4.2 (95% CI, 3.8-4.7) with digital mammography vs 5.4 (95% CI, 4.9-6.0) with digital mammography + tomosynthesis; difference, 1.2 (95% CI, 0.8-1.6; P < .001); and for invasive cancer detection, 2.9 (95% CI, 2.5-3.2) with digital mammography vs 4.1 (95% CI, 3.7-4.5) with digital mammography + tomosynthesis; difference, 1.2 (95% CI, 0.8-1.6; P < .001). The in situ cancer detection rate was 1.4 (95% CI, 1.2-1.6) per 1000 screens with both methods. Adding tomosynthesis was associated with an increase in the positive predictive value for recall from 4.3% to 6.4% (difference, 2.1%; 95% CI, 1.7%-2.5%; P < .001) and for biopsy from 24.2% to 29.2% (difference, 5.0%; 95% CI, 3.0%-7.0%; P < .001). CONCLUSIONS AND RELEVANCE Addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. Further studies are needed to assess the relationship to clinical outcomes.

Breast Cancer Screening Using Tomosynthesis and Digital Mammography in Dense and Nondense Breasts

its subsidiaries inthe United States and/or other countries. This information is intended for medical professionals in the U.S. and other markets and is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible to control where such materials appear. For specific information on what products are available for sale in a particular country, please contact your local Hologic representative or write to womenshealth@hologic.com. DIVISIONAL HEADER

Vascular and nonvascular complications of liver transplants: sonographic evaluation and correlation with other imaging modalities and findings at surgery and pathology.

Liver transplantation is performed in adults and children to treat patients with irreversible liver damage when medical or other surgical treatment has failed. The most common indications for transplantation are cirrhosis secondary to fulminant acute hepatitis or chronic active hepatitis, sclerosing cholangitis, primary biliary cirrhosis, Budd–Chiari syndrome, inborn errors of metabolism, and unresectable but local hepatocellular carcinoma. This article reviews the sonographic findings in the preoperative evaluation of liver transplant recipients, briefly describes the surgical technique, and demonstrates normal postoperative findings in liver transplant recipients as well as complications associated with liver transplantation.

Breast Cancer Screening With Tomosynthesis and Digital Mammography—Reply

The likelihood of this magnitude of imbalance is not known; from a clinical perspective it seems low, but it is possible that clusters of unmeasured confounders could create large imbalances. Even though the methods used in their study were sophisticated, observational studies are vulnerable to residual confounding. For example, a large body of observational data on the relationship between cardiovascular disease and postmenopausal hormone therapy overwhelmingly suggested benefit prior to the Women’s Health Initiative Clinical Trial, which proved that hormone therapy did not reduce the risk of heart disease and actually increased the risk of stroke.2,3 I agree with Roumie and colleagues that well-performed observational studies such as theirs provide invaluable information for both patients and their physicians, but I also urge caution in drawing causal inferences based on observational data, even with highly sophisticated analytic methods.

Impact of a False-Positive Screening Mammogram on Subsequent Screening Behavior and Stage at Breast Cancer Diagnosis

Background: Experiencing a false positive (FP) screening mammogram is economically, physically, and emotionally burdensome, which may affect future screening behavior by delaying the next scheduled mammogram or by avoiding screening altogether. We sought to examine the impact of a FP screening mammogram on the subsequent screening mammography behavior. Methods: Delay in obtaining subsequent screening was defined as any mammogram performed more than 12 months from index mammogram. The Kaplan–Meier (product limit) estimator and Cox proportional hazards model were used to estimate the unadjusted delay and the hazard ratio (HR) of delay of the subsequent screening mammogram within the next 36 months from the index mammogram date. Results: A total of 650,232 true negative (TN) and 90,918 FP mammograms from 261,767 women were included. The likelihood of a subsequent mammogram was higher in women experiencing a TN result than women experiencing a FP result (85.0% vs. 77.9%, P < 0.001). The median delay in returning to screening was higher for FP versus TN (13 months vs. 3 months, P < 0.001). Women with TN result were 36% more likely to return to screening in the next 36 months compared with women with a FP result HR = 1.36 (95% CI, 1.35–1.37). Experiencing a FP mammogram increases the risk of late stage at diagnosis compared with prior TN mammogram (P < 0.001). Conclusions: Women with a FP mammogram were more likely to delay their subsequent screening compared with women with a TN mammogram. Impact: A prior FP experience may subsequently increase the 4-year cumulative risk of late stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 26(3); 397–403. ©2017 AACR.

Radiology as the Point of Cancer Patient and Care Team Engagement: Applying the 4R Model at a Patient’s Breast Cancer Care Initiation

Radiologists aspire to improve patient experience and engagement, as part of the Triple Aim of health reform. Patient engagement requires active partnerships among health providers and patients, and rigorous teamwork provides a mechanism for this. Patient and care team engagement are crucial at the time of cancer diagnosis and care initiation but are complicated by the necessity to orchestrate many interdependent consultations and care events in a short time. Radiology often serves as the patient entry point into the cancer care system, especially for breast cancer. It is uniquely positioned to play the value-adding role of facilitating patient and team engagement during cancer care initiation. The 4R approach (Right Information and Right Care to the Right Patient at the Right Time), previously proposed for optimizing teamwork and care delivery during cancer treatment, could be applied at the time of diagnosis. The 4R approach considers care for every patient with cancer as a project, using project management to plan and manage care interdependencies, assign clear responsibilities, and designate a quarterback function. The authors propose that radiology assume the quarterback function during breast cancer care initiation, developing the care initiation sequence, as a project care plan for newly diagnosed patients, and engaging patients and their care teams in timely, coordinated activities. After initial consultations and treatment plan development, the quarterback function is transitioned to surgery or medical oncology. This model provides radiologists with opportunities to offer value-added services and solidifies radiologys relevance in the evolving health care environment. To implement 4R at cancer care initiation, it will be necessary to change the radiology practice model to incorporate patient interaction and teamwork, develop 4R content and local adaption approaches, and enrich radiology training with relevant clinical knowledge, patient interaction competence, and teamwork skill set.

Breast Tomosynthesis: Practical Considerations

Digital breast tomosynthesis (DBT) is rapidly becoming the new standard of care for breast cancer screening. DBT has improved on the limitations of traditional digital mammography by increasing cancer detection and decreasing false-positive examinations. Interpretation of DBT is slightly different than digital mammography and therefore experience with the technology is paramount to achieve best performance. Examples of malignancies that should be recalled and benign findings that are safely called as benign are provided in this article. Additionally, practical interpretation methods and implementation protocols are explained.

Breast Cancer Screening: The Debate that Never Ends

Screening mammography has been shown to decrease breast cancer deaths through randomized controlled trials. However, there remains significant debate surrounding the most appropriate time to commence screening and the optimal screening interval. Several national organizations have recently updated their guidelines by reanalyzing the published data. Interestingly, each organization has come to different conclusions regarding their recommendation for breast cancer screening in the average risk woman. Three of the main organizations that issue guidelines for breast cancer screening in the United States are reviewd in this chapter.

Lesion localization using the scroll bar on tomosynthesis: Why doesn't it always work?

The scroll bar on digital breast tomosynthesis (DBT) is an important tool that facilitates localization of lesions on the orthogonal view. While this works well most of the time, occasionally the location of the lesion as directed by the scroll bar is seemingly inaccurate. There are five important reasons why the scroll bar indicator may suggest a contradictory lesion location. Understanding specific scenarios when this may occur will aid the reader in reconciling these differences.

Performance characteristics of digital vs film screen mammography in community practice

We compared the performance characteristics of 297 629 full field digital (FFDM) and 416 791 screen film mammograms (SFM). Sensitivity increased with age, decreased with breast density, and was lower for more aggressive and lobular tumors. While sensitivity did not differ significantly by modality, specificity was generally 1%‐2% points higher for FFDM than for SFM across age and breast density categories. The lower recall rate for FFDM vs SFM in our study may partially explain performance differences by modality. In this large health care organization, modest gains in performance were achieved with the introduction of FFDM as a replacement for SFM.