Effects of delayed callback from screening mammography due to the COVID-19 pandemic.

OBJECTIVE: To determine the frequency and distinguishing imaging characteristics of breast cancers detected on screening mammography which was initially evaluated as a probably benign lesion and the workup was delayed due to the COVID-19 pandemic. MATERIALS AND METHODS: REB-approved multicenter retrospective screening mammography studies and patient's chart review carried out between February 2020 and March 2020. According to an institutional decision, the frequency and imaging findings deemed probably benign on screening mammography after review by a breast fellowship-trained radiologist with workup deferred until after the first pandemic wave plateau in late July 2020 were recorded. Results were correlated with histopathology if tissue sample performed or an uneventful 2 years follow-up. Descriptive statistical analysis was used to describe the retrieved data set. RESULTS: Out of 1816 mammography screening between February 2020 and March 2020, 99 women, median age 58 years (range 35-84), 99 mammography had possibly benign findings with workup delayed, and two patients, age 49 and 56, had cancers (2.02%), misinterpreted as benign findings. Both malignant cases were focal asymmetries, with pathology of invasive ductal carcinoma, 12 mm and 9 mm in size. No in-situ carcinoma was detected. CONCLUSION: The low rate of cancer detected suggests that a delay callback may be a reasonable option for some likely benign findings when immediate callback is not an option, such as during a pandemic. Larger studies would be helpful to support our findings and may allow us to translate the adoption of such a model during potential future pandemic. CLINICAL RELEVANCE: The results of this study may be helpful for a future situation when delaying a call back from screening mammography is again required.

The role of facility and patient mix factors on recovery of screening and diagnostic mammography volumes following the initial COVID-19 pandemic wave.

INTRODUCTION: The goal of this study was to understand the extent to which mammography facilities were able to recover monthly screening and diagnostic mammography volumes to their prepandemic levels and to determine what facility and patient mix factors were associated with recovery. METHOD: Facilities, located in and adjacent to Cook County, Illinois, were eligible. In all, 58 screening and 30 diagnostic mammogram facilities submitted mammogram volumes by month with a cross-listing of patient ZIP codes by screening volumes. Monthly screening and diagnostic volumes for the 6-month immediate postpandemic period (July-December 2020) and for the subsequent postpandemic period (January-June 2021) were compared with the same months in 2019. ZIP code distributions were used to define patient mix characteristics related to disadvantage. RESULTS: Compared with the prepandemic period, Breast Imaging Centers of Excellence conducted roughly 50 fewer monthly screening mammograms (95% CI: -91, -9) but 50 more diagnostic mammograms (95% CI: 24, 82) on average in the immediate postpandemic period. Facilities serving a predominantly Black population conducted roughly 50 fewer monthly screens (95% CI: -93, -13) without any increase in monthly diagnostics. CONCLUSION: Highly accredited (and typically higher volume) facilities appeared to actively triage diagnostics, whereas lower resource facilities appeared to struggle to recover to prepandemic volumes without triage to diagnostics. The pandemic disproportionally impacted minority populations already affected by differential access to and utilization of high-quality mammography. Potential explanations are discussed. Policies should be strengthened to facilitate triaging of services during times of stress to the healthcare system.

Live Mammographic Screening Interpretation Versus Offline Same-Day Screening Interpretation at a Tertiary Cancer Center.

OBJECTIVES: The aim of this study was to compare screening mammography performance metrics for immediate (live) interpretation versus offline interpretation at a cancer center. METHODS: An institutional review board-approved, retrospective comparison of screening mammography metrics at a cancer center for January 1, 2018, to December 31, 2019 (live period), and September 1, 2020, to March 31, 2022 (offline period), was performed. Before July 2020, screening examinations were interpreted while patients waited (live period), and diagnostic workup was performed concurrently. After the coronavirus disease 2019 shutdown from March to mid-June 2020, offline same-day interpretation was instituted. Patients with abnormal screening results returned for separate diagnostic evaluation. Screening metrics of positive predictive value 1 (PPV1), cancer detection rate (CDR), and abnormal interpretation rate (AIR) were compared for 17 radiologists who interpreted during both periods. Statistical significance was assessed using χ2 analysis. RESULTS: In the live period, there were 7,105 screenings, 635 recalls, and 51 screen-detected cancers. In the offline period, there were 7,512 screenings, 586 recalls, and 47 screen-detected cancers. Comparison of live screening metrics versus offline metrics produced the following results: AIR, 8.9% (635 of 7,105) versus 7.8% (586 of 7,512) (P = .01); PPV1, 8.0% (51 of 635) versus 8.0% (47 of 586); and CDR, 7.2/1,000 versus 6.3/1,000 (P = .50). When grouped by >10% AIR or <10% AIR for the live period, the >10% AIR group showed a significant decrease in AIR for offline interpretation (from 12.7% to 9.7%, P < .001), whereas the <10% AIR group showed no significant change (from 7.4% to 6.7%, P = .17). CONCLUSIONS: Conversion to offline screening interpretation from immediate interpretation at a cancer center was associated with lower AIR and similar CDR and PPV1. This effect was seen largely in radiologists with AIR > 10% in the live setting.

Breast and Lung Cancer Screening Among Medicare Enrollees During the COVID-19 Pandemic.

Importance: Several studies reported sharp decreases in screening mammography for breast cancer and low-dose computed tomographic screening for lung cancer in the early months of the COVID-19 pandemic, followed by a return to normal or near-normal levels in the summer of 2020. Objective: To determine the observed vs expected mammography and low-dose computed tomographic scan rates from the beginning of the pandemic through April 2022. Design, Setting, and Participants: In this retrospective cohort study assessing mammography and low-dose computed tomography rates from January 2017 through April 2022, data for January 2016 to February 2020 were used to generate expected rates for the period March 2020 to April 2022. The study included a 20% national sample of Medicare fee-for-service enrollees among women aged 50 to 74 years for mammography, and men and women aged 55 to 79 years for low-dose computed tomographic scan. Main Outcomes and Measures: Receipt of screening mammography or low-dose computed tomographic scan. Results: The yearly cohorts for the mammography rates included more than 1 600 000 women aged 50 to 74 years, and the cohorts for the low-dose computed tomographic scan rates included more than 3 700 000 men and women aged 55 to 79 years. From January 2017 through February 2020, monthly mammography rates were flat, whereas there was a monotonic increase in low-dose computed tomographic scan rates, from approximately 500 per million per month in early 2017 to 1100 per million per month by January 2020. Over the period from March 2020 to April 2022, there were episodic drops in both mammography and low-dose computed tomographic scan rates, coincident with increases in national COVID-19 infection rates. For the periods from March 2020 to February 2020 and March 2021 to February 2022, the observed low-dose computed tomographic scan rates were 24% (95% CI, 23%-24%) and 14% (95% CI, 13%-15%) below expected rates, whereas mammography rates were 17% (95% CI, 17%-18%) and 4% (95% CI, 4%-3%) below expected. Conclusions and Relevance: In this cohort study, the decreases in cancer screening during the early phases of the COVID-19 pandemic did not resolve after the initial pandemic surges. Successful interventions to improve screening rates should address pandemic-specific reasons for low screening participation.

Long-term effects of the interruption of the Dutch breast cancer screening program due to COVID-19: A modelling study.

Due to COVID-19, the Dutch breast cancer screening program was interrupted for three months with uncertain long-term effects. The aim of this study was to estimate the long-term impact of this interruption on delay in detection, tumour size of screen-detected breast cancers, and interval cancer rate. After validation, the micro-simulation model SiMRiSc was used to calculate the effects of interruption of the breast cancer screening program for three months and for hypothetical interruptions of six and twelve months. A scenario without interruption was used as reference. Outcomes considered were tumour size of screen-detected breast cancers and interval cancer rate. Women of 55-59 and 60-64 years old at time of interruption were considered. Uncertainties were estimated using a sensitivity analysis. The three-month interruption had no clinically relevant long-term effect on the tumour size of screen-detected breast cancers. A 19% increase in interval cancer rate was found between last screening before and first screening after interruption compared to no interruption. Hypothetical interruptions of six and twelve months resulted in larger increases in interval cancer rate of 38% and 78% between last screening before and first screening after interruption, respectively, and an increase in middle-sized tumours in first screening after interruption of 26% and 47%, respectively. In conclusion, the interruption of the Dutch screening program is not expected to result in a long-term delay in detection or clinically relevant change in tumour size of screen-detected cancers, but only affects the interval cancer rate between last screening before and first screening after interruption.

Screening Mammography Recovery After COVID-19 Pandemic Facility Closures: Associations of Facility Access and Racial and Ethnic Screening Disparities.

BACKGROUND. Screening mammography facilities closed during the COVID-19 pandemic in spring 2020. Recovery of screening volumes has varied across patient subgroups and facilities. OBJECTIVE. We compared screening mammography volumes and patient and facility characteristics between periods before COVID-19 and early and later postclosure recovery periods. METHODS. This retrospective study included screening mammograms performed in the same 2-month period (May 26-July 26) in 2019 (pre-COVID-19), 2020 (early recovery), and 2021 (late recovery after targeted interventions to expand access) and across multiple facility types (urban, suburban, community health center). Suburban sites had highest proportion of White patients and the greatest scheduling flexibility and expanded appointments during initial reopening. Findings were compared across years. RESULTS. For White patients, volumes decreased 36.6% from 6550 in 2019 (4384 in 2020) and then increased 61.0% to 6579 in 2021; for patients with races other than White, volumes decreased 53.9% from 1321 in 2019 (609 in 2020) and then increased 136.8% to 1442 in 2021. The percentage of mammograms in patients with races other than White was 16.8% in 2019, 12.2% in 2020, and 18.0% in 2021. The proportion performed at the urban center was 55.3% in 2019, 42.2% in 2020, and 45.9% in 2021; the proportion at suburban sites was 34.0% in 2019, 49.2% in 2020, and 43.5% in 2021. Pre-COVID-19 volumes were reached by the sixth week after reopening for suburban sites but were not reached during early recovery for the other sites. The proportion that were performed on Saturday for suburban sites was similar across periods, whereas the proportion performed on Saturday for the urban site was 7.6% in 2019, 5.3% in 2020, and 8.8% in 2021; the community health center did not offer Saturday appointments during recovery. CONCLUSION. After reopening, screening shifted from urban to suburban settings, with a disproportionate screening decrease in patients with races other than White. Initial delayed access at facilities serving underserved populations exacerbated disparities. Interventions to expand access resulted in late recovery volumes exceeding prepandemic volumes in patients with races other than White. CLINICAL IMPACT. Interventions to support equitable access across facilities serving diverse patient populations may mitigate potential widening disparities in breast cancer diagnosis during the pandemic.

Misinformation and Facts about Breast Cancer Screening.

Quality medical practice is based on science and evidence. For over a half-century, the efficacy of breast cancer screening has been challenged, particularly for women aged 40-49. As each false claim has been raised, it has been addressed and refuted based on science and evidence. Nevertheless, misinformation continues to be promoted, resulting in confusion for women and their physicians. Early detection has been proven to save lives for women aged 40-74 in randomized controlled trials of mammography screening. Observational studies, failure analyses, and incidence of death studies have provided evidence that there is a major benefit when screening is introduced to the general population. In large part due to screening, there has been an over 40% decline in deaths from breast cancer since 1990. Nevertheless, misinformation about screening continues to be promoted, adding to the confusion. Despite claims to the contrary, a careful reading of the guidelines issued by major groups such as the U.S. Preventive Services Task Force and the American College of Physicians shows that they all agree that most lives are saved by screening starting at the age of 40. There is no scientific support for using the age of 50 as a threshold for screening. All women should be provided with the facts and not false information about breast cancer screening so that they can make "informed decisions" for themselves about whether to participate.

Trends in breast and prostate cancer screening and diagnostic procedures during the COVID-19 pandemic in central Massachusetts.

PURPOSE: We calculated rates of breast and prostate cancer screening and diagnostic procedures performed during the COVID-19 pandemic through December 2021 compared to the same months in 2019 in a large healthcare provider group in central Massachusetts. METHODS: We included active patients of the provider group between January 2019 and December 2021 aged 30-85 years. Monthly rates of screening mammography and digital breast tomosynthesis, breast MRI, total prostate specific antigen (PSA), and breast or prostate biopsy per 1,000 people were compared by year overall, by age, and race/ethnicity. Completed procedures were identified by relevant codes in electronic health record data. RESULTS: Rates of screening mammography, tomosynthesis, and PSA testing reached the lowest levels in April-May 2020. Breast cancer screening rates decreased 43% in March and 99% in April and May 2020, compared to 2019. Breast cancer screening rates increased gradually beginning in June 2020 through 2021, although more slowly in Black and Hispanic women and in women aged 75-85. PSA testing rates decreased 34% in March, 78% in April, and 53% in May 2020, but rebounded to pre-pandemic levels by June 2020; trends were similar across groups defined by age and race/ethnicity. CONCLUSION: The observed decline in two common screening procedures during the COVID-19 pandemic reflects the impact of the pandemic on cancer early detection and signals potential downstream effects on the prognosis of delayed cancer diagnoses. The slower rate of return for breast cancer screening procedures in certain subgroups should be investigated to ensure all women return for routine screenings.

Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic.

BACKGROUND. The need for second visits between screening mammography and diagnostic imaging contributes to disparities in the time to breast cancer diagnosis. During the COVID-19 pandemic, an immediate-read screening mammography program was implemented to reduce patient visits and decrease time to diagnostic imaging. OBJECTIVE. The purpose of this study was to measure the impact of an immediate-read screening program with focus on disparities in same-day diagnostic imaging after abnormal findings are made at screening mammography. METHODS. In May 2020, an immediate-read screening program was implemented whereby a dedicated breast imaging radiologist interpreted all screening mammograms in real time; patients received results before discharge; and efforts were made to perform any recommended diagnostic imaging during the visit (performed by different radiologists). Screening mammographic examinations performed from June 1, 2019, through October 31, 2019 (preimplementation period), and from June 1, 2020, through October 31, 2020 (postimplementation period), were retrospectively identified. Patient characteristics were recorded from the electronic medical record. Multivariable logistic regression models incorporating patient age, race and ethnicity, language, and insurance type were estimated to identify factors associated with same-day diagnostic imaging. Screening metrics were compared between periods. RESULTS. A total of 8222 preimplementation and 7235 postimplementation screening examinations were included; 521 patients had abnormal screening findings before implementation, and 359 after implementation. Before implementation, 14.8% of patients underwent same-day diagnostic imaging after abnormal screening mammograms. This percentage increased to 60.7% after implementation. Before implementation, patients who identified their race as other than White had significantly lower odds than patients who identified their race as White of undergoing same-day diagnostic imaging after receiving abnormal screening results (adjusted odds ratio, 0.30; 95% CI, 0.10-0.86; p = .03). After implementation, the odds of same-day diagnostic imaging were not significantly different between patients of other races and White patients (adjusted odds ratio, 0.92; 95% CI, 0.50-1.71; p = .80). After implementation, there was no significant difference in race and ethnicity between patients who underwent and those who did not undergo same-day diagnostic imaging after receiving abnormal results of screening mammography (p > .05). The rate of abnormal interpretation was significantly lower after than it was before implementation (5.0% vs 6.3%; p < .001). Cancer detection rate and PPV1 (PPV based on positive findings at screening examination) were not significantly different before and after implementation (p > .05). CONCLUSION. Implementation of the immediate-read screening mammography program reduced prior racial and ethnic disparities in same-day diagnostic imaging after abnormal screening mammograms. CLINICAL IMPACT. An immediate-read screening program provides a new paradigm for improved screening mammography workflow that allows more rapid diagnostic workup with reduced disparities in care.

Limiting Screening Mammography Recalls for Vaccine-Induced Adenopathy, a Single Institution Experience.

RATIONALE AND OBJECTIVES: Reported incidence of vaccine-induced adenopathy varies widely, with higher estimates in early reports and small series. Objective was to evaluate a large sample of vaccinated patients undergoing screening mammography, to determine callback rates associated with vaccine-induced adenopathy and their outcomes. MATERIALS AND METHODS: Single-institution retrospective review of patients who received at least 1 dose of a COVID-19 vaccine prior to presentation for screening mammography from January 15 through May 31, 2021. Patient-related vaccination information (dose, brand, arm, date) was obtained by mammography technologists and available for interpreting radiologists. Patients recalled for axillary adenopathy were included; other causes for recall were excluded. Follow-up imaging and outcomes were tracked. Wilcoxon rank-sum test, Fisher exact test, multivariable logistic regression modeling, and receiver operating characteristic curve analyses were utilized. All tests were two-sided; p < 0.05 considered statistically significant. RESULTS: Total of 2304 vaccinated patients underwent screening mammography; 24 (1.0%) recalled for ipsilateral adenopathy. There was no significant difference in presence of adenopathy associated with patient age, dose, or brand of vaccine. Presence of adenopathy significantly decreased as days from vaccination increased (p < 0.001). Receiver operating characteristic curve suggested 28.5 days as the best cutoff point to distinguish presence or absence of adenopathy on mammogram. Of 24 callbacks, 13 (54.2%) had benign results, 2 (8.3%) are still undergoing surveillance, and 9 (37.5%) are overdue for subsequent follow-ups. No cases resulted in biopsy or malignancy. CONCLUSION: Low recall rates related to vaccine-induced adenopathy are achievable and can limit unnecessary workups, improve access, and promote flexible timing of vaccinations and screening exams.

The PROCEM study protocol: Added value of preoperative contrast-enhanced mammography in staging of malignant breast lesions - a prospective randomized multicenter study.

BACKGROUND: Correct preoperative estimation of the malignant extent is crucial for optimal planning of breast cancer surgery. The sensitivity of mammography is lower in dense breasts, and additional imaging techniques are sometimes warranted. Contrast-enhanced mammography (CEM) has shown similar sensitivity and in some cases better specificity, than magnetic resonance imaging (MRI) in small, observational studies. CEM may be more cost-effective than MRI, and may provide better identification of the tumor extent, however, no randomized trials have been performed to date to investigate the added value of CEM. In a feasibility study, we found that the treatment was changed in 10/47 (21%) cases after additional CEM. The purpose of the present study is to evaluate the added value of CEM in preoperative staging of breast cancer in a randomized study. METHOD: This prospective randomized study will include 440 patients with strongly suspected or established diagnosis of breast malignancy, based on assessment with mammography, ultrasound and core biopsy/cytology, and for whom primary surgery is planned. Patients will be randomized 1:1 using a web-based randomization tool to additional investigation with CEM or no further imaging. The CEM findings will be taken into consideration, which may lead to changes in primary treatment, which is the primary endpoint of this study. Secondary endpoints include rate of reoperation and number of avoidable mastectomies, as well as a cost-benefit analysis of additional CEM. Patient-reported health-related quality of life will be investigated at 1 year with the validated Breast-Q™ questionnaire. The rate of local recurrence or new cancer ipsi- or contralaterally within 5 years will be assessed from medical records and pathology reports. DISCUSSION: The aim of this trial is to explore the added value of CEM in preoperative staging of breast cancer. The results obtained from this study will contribute to our knowledge on CEM as an additional imaging method to standard investigation with digital mammography and ultrasound. The findings may also provide additional information on which patient groups would benefit from CEM, and on the economic aspects of CEM in standard preoperative practice. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov , registration no: NCT04437602 , date of registration: June 18, 2020.

Impact of adding breast density to breast cancer risk models: A systematic review.

PURPOSE: Assessment of a woman's risk of breast cancer is essential when moving towards personalized screening. Breast density is a well-known risk factor and has the potential to improve accuracy of risk prediction models. In this study we reviewed the impact on model performance of adding breast density to clinical breast cancer risk prediction models. METHODS: We conducted a systematic review using a pre-specified search strategy for PubMed, EMBASE, Web of Science, and Cochrane Library from January 2007 until November 2019. Studies were screened using the Covidence software. Eligible studies developed or modified existing breast cancer risk prediction models applicable to the general population of women by adding breast density to the model. Improvement in discriminatory accuracy was measured as an increase in the Area Under the Curve or concordance statistics. RESULTS: Eleven eligible studies were identified by the search and one by reference check. Four studies modified the Gail model, four modified the Tyrer-Cuzick model, and five studies developed new models. Several methods were used to measure breast density, including visual, semi- and fully automated methods. Eleven studies reported discriminatory accuracy and one study reported calibration. Seven studies found a statistically significantly increased discriminatory accuracy when including density in the model. The increase in AUC ranged 0.03 to 0.14. Four studies did not report on statistical significance, but reported an increased AUC ranging from 0.01 to 0.06. CONCLUSION: Including mammographic breast density has the potential to improve breast cancer risk prediction models. However, all models demonstrated limited discrimination accuracy.

COVID-19 Vaccination-Associated Axillary Adenopathy: Imaging Findings and Follow-Up Recommendations in 23 Women.

The purpose of this article is to report on 23 women with evidence of axillary adenopathy at breast imaging after recent COVID-19 vaccination. A total of 13% of patients had symptoms (axillary lump), 43% were undergoing screening, and 43% were undergoing diagnostic imaging for other reasons. BI-RADS category 2 was assigned in one case, BI-RADS 3 in 21 (ultrasound in 4-24 weeks), and BI-RADS 4 in one. Radiologist familiarity and evidence-based guidelines are needed to avoid follow-up imaging and biopsies for reactive adenopathy after COVID-19 vaccination.

Imaging, Paternalism and the Worried Patient: Rethinking Our Approach.

The Covid pandemic has taught many lessons, including the importance of mental health. The value of the radiologist in holistic patient care may be underestimated and underresearched. Barriers to the acceptance of imaging as an important component in reassurance may be rooted in old ideas minimizing the importance of mental health.

Practical approach to prevent COVID-19 infection at breast cancer screening.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) undermines the benefits of cancer screening. To date, no study has identified specific infection control methods. We aimed to provide practical methods for COVID-19 risk reduction during breast cancer screening mammography (MMG) by examining an overview of potential contamination routes of aerosols and possible risks for patients and health care providers. METHODS: Computational fluid dynamics (CFD) simulations were conducted for airflow and aerosol dispersion in a 3D virtual model of a mobile MMG laboratory room. This model was constructed based on the actual mobile screening MMG bus 'Cosmos' in the Chiba Foundation for Health Promotion & Disease Prevention. Examiner and patient geometries were obtained by scanning an actual human using a 3D Scanner. Contamination of the room was evaluated by counting the numbers of suspended and deposited aerosols. RESULTS: We applied the CFD simulation model to the exhalation of small or large aerosols from a patient and examiner in the MMG laboratory. Only 14.5% and 54.5% of large and small aerosols, respectively, were discharged out of the room with two doors open. In contrast, the proportion of large and small aerosols discharged out of the room increased to 96.6% and 97.9%, respectively, with the addition of forced gentle wind by the blower fan. This simulation was verified by a mist aerosol experiment conducted in the mobile MMG laboratory. CONCLUSION: Adding forced ventilation to a MMG laboratory with two doors open may enable risk reduction dramatically. This could be applied to other clinical situations.

The Impact of the COVID-19 Pandemic on Breast Imaging.

"Starting in Wuhan, China, followed quickly in the United States in January 2020, an outbreak of a novel coronavirus, or COVID-19, escalated to a global pandemic by March. Significant disruptions occurred to breast imaging, including deferred screening mammography, triaging diagnostic breast imaging, and changes in breast cancer care algorithms. This article summarizes the effect of the global pandemic-and efforts to curtail its spread-on both breast cancer care and on breast imaging practices including effects on patients, clinical workflow, education, and research."

Effects of the COVID-19 pandemic on breast cancer screening in Taiwan.

The breast cancer screening program has continued in Taiwan during the COVID-19 pandemic. Our nationwide data showed that the total number of screenings decreased by 22.2%, which was more pronounced for in-hospital examinations (-37.2%), while outreach showed a 12.9% decrease. This decline in screening participation happened at all levels of hospitals, more significantly at the highest level. Our report revealed that outreach services could maintain relatively stable breast cancer screening under this kind of public health crisis. Building a flexible, outreach system into the community might need to be considered when policymakers are preparing for future possible pandemics.