Predictors of re-attendance at biennial screening mammography following a false positive referral: A study among women in the south of the Netherlands.

AIM: A false positive (FP) referral after screening mammography may influence a woman's likelihood to re-attend the screening program. The impact of having a FP result in the first or subsequent screening round on re-attendance after a FP result was investigated. In addition, we aimed to study differences in re-attendance rates between women who underwent non-invasive and invasive additional examinations as part of the diagnostic work-up following a FP referral. METHODS: A consecutive series of 13,597 women with a FP referral following biennial screening mammography in the south of the Netherlands between 2009 and 2019 was included. RESULTS: The screening re-attendance rate was 81.2% after a FP referral, and 91.3% when also including women who had clinical mammographic follow-up. Women who received a FP referral in the first screening round were less likely to re-attend the screening programme in the following three years, compared to those with a FP test in any subsequent round (odds ratio (OR): 0.59, 95%-confidence interval (CI): 0.51-0.69). Women with a FP referral who underwent invasive examinations after referral were less likely to re-attend the screening programme than those who only received additional imaging (OR, 0.48; 95% CI 0.36-0.64). CONCLUSION: Women with a FP referral are less likely to re-attend the screening programme if this referral occurs at their first screening round or when they undergo invasive diagnostic workup. Hospitals and screening organizations should prioritize informing women about the importance of re-attending the programme following a FP referral.

Long-term trends in incidence, characteristics and prognosis of screen-detected and interval cancers in women participating in the Dutch breast cancer screening programme.

BACKGROUND: No studies are available in which changes over time in characteristics and prognosis of patients with interval breast cancers (ICs) and screen-detected breast cancers (SDCs) have been compared. The aim was to study these trends between 1995 and 2018. METHODS: All women with invasive SDCs (N = 4290) and ICs (N = 1352), diagnosed in a southern mammography screening region in the Netherlands, were included and followed until date of death or 31 December 2022. RESULTS: The 5-year overall survival rate of women with SDCs increased from 91.4% for those diagnosed in 1995-1999 to 95.0% for those diagnosed in 2013-2018 (P < 0.001), and from 74.8 to 91.6% (P < 0.001) in the same periods for those with ICs. A similar trend was observed for the 10-year survival rates. After adjustment for changes in tumour characteristics, the hazard ratio (HR) for overall survival was 0.47 (95% confidence interval (CI): 0.38-0.59) for women with SDCs diagnosed in the period 2013-2018, compared to the women diagnosed in the period 1995-1999. For the women with ICs this HR was 0.27 (95% CI: 0.19-0.40). CONCLUSION: The prognosis of women with ICs has improved rapidly since 1995 and is now almost similar to that of women with SDCs.

Trends in the pre-operative diagnosis and surgical management of axillary lymph node metastases in women with screen-detected breast cancer.

AIM: The aim of the current study was to investigate time-trends in pre-operative diagnosis and surgical treatment of axillary lymph node metastases in breast cancers detected at screening mammography. METHODS: We included all women who underwent screening mammography in the South of the Netherlands between 2005 and 2020. During a follow-up period of at least two years, data on clinical radiological examinations, biopsy procedures and surgical interventions were obtained. The 15 years of inclusion were divided into five cohorts of three years each. RESULTS: Of the 4049 women with invasive breast cancer, 22.1 % (896/4049) had axillary lymph node metastasis at pathology (ALN+). Percutaneous axillary biopsy was performed in 39.6 % (355/896) of these women, with the proportions of fine needle aspiration biopsy (FNAB) decreasing from 97.6 % (40/41) in 2005-2007 to 41.6 % (37/89) in 2017-2019 and core needle biopsy (CNB) rising from 2.4 % (1/41) in 2005-2007 to 58.4 % (52/89) in 2017-2019 (P < 0.001). Sensitivity of FNAB and CNB was comparable (77.4 % (188/243, 95%CI = 71%-82 %) versus 82.4 % (103/125), 95%CI = 74%-88 %) (P = 0.26). Pre-operative confirmation of ALN + by percutaneous biopsy ranged from 27.3 % (56/205) in 2011-2013 to 39.0 % (80/205) in 2017-2019, with no significant trend changes over time (P = 0.103). The proportion of ALN + women who underwent axillary lymph node dissection (ALND) decreased from 96.0 % (97/101) in 2005-2007 to 16.6 % (34/205) in 2017-2019 (P < 0.001). CONCLUSION: Pre-operative confirmation of axillary lymph node metastasis by ultrasound-guided biopsy did not rise despite the increased use of CNB at the expense of less invasive FNAB. A significant reduction in ALND was observed through the years.

International Interobserver Variability of Breast Density Assessment.

PURPOSE: The aim of this study was to determine variability in visually assessed mammographic breast density categorization among radiologists practicing in Indonesia, the Netherlands, South Africa, and the United States. METHODS: Two hundred consecutive 2-D full-field digital screening mammograms obtained from September to December 2017 were selected and retrospectively reviewed from four global locations, for a total of 800 mammograms. Three breast radiologists in each location (team) provided consensus density assessments of all 800 mammograms using BI-RADS® density categorization. Interreader agreement was compared using Gwet's AC2 with quadratic weighting across all four density categories and Gwet's AC1 for binary comparison of combined not dense versus dense categories. Variability of distribution among teams was calculated using the Stuart-Maxwell test of marginal homogeneity across all four categories and using the McNemar test for not dense versus dense categories. To compare readers from a particular country on their own 200 mammograms versus the other three teams, density distribution was calculated using conditional logistic regression. RESULTS: For all 800 mammograms, interreader weighted agreement for distribution among four density categories was 0.86 (Gwet's AC2 with quadratic weighting; 95% confidence interval, 0.85-0.88), and for not dense versus dense categories, it was 0.66 (Gwet's AC1; 95% confidence interval, 0.63-0.70). Density distribution across four density categories was significantly different when teams were compared with one another and one team versus the other three teams combined (P < .001). Overall, all readers placed the largest number of mammograms in the scattered and heterogeneous categories. CONCLUSIONS: Although reader teams from four different global locations had almost perfect interreader agreement in BI-RADS density categorization, variability in density distribution across four categories remained statistically significant.

The dilemma of recalling well-circumscribed masses in a screening population: A narrative literature review and exploration of Dutch screening practice.

BACKGROUND: In Dutch breast cancer screening, solitary, new or growing well-circumscribed masses should be recalled for further assessment. This results in cancers detected but also in false positive recalls, especially at initial screening. The aim of this study was to determine characteristics of well-circumscribed masses at mammography and identify potential methods to improve the recall strategy. METHODS: A systematic literature search was performed using PubMed. In addition, follow-up data were retrieved on all 8860 recalled women in a Dutch screening region from 2014 to 2019. RESULTS: Based on 15 articles identified in the literature search, we found that probably benign well-circumscribed masses that were kept under surveillance had a positive predictive value (PPV) of 0-2%. New or enlarging solitary well-circumscribed masses had a PPV of 10-12%. In general the detected carcinomas had a favorable prognosis. In our exploration of screening practice, 25% of recalls (2133/8860) were triggered by a well-circumscribed mass. Those recalls had a PPV of 2.0% for initial and 10.6% for subsequent screening. Most detected carcinomas had a favorable prognosis as well. CONCLUSION: To recognize malignancies presenting as well-circumscribed masses, identifying solitary, new or growing lesions is key. This information is missing at initial screening since prior examinations are not available, leading to a low PPV. Access to prior clinical examinations may therefore improve this PPV. In addition, given the generally favorable prognosis of screen-detected malignant well-circumscribed masses, one may opt to recall these lesions at subsequent screening, if grown, rather than at initial screening.

Clinical value of contralateral breast cancers detected by pre-operative MRI in patients diagnosed with DCIS: a population-based cohort study.

OBJECTIVES: For patients with ductal carcinoma in situ (DCIS), data about the impact of breast MRI at primary diagnosis on the incidence and characteristics of contralateral breast cancers are scarce. METHODS: We selected all 8486 women diagnosed with primary DCIS in the Netherlands in 2011-2015 from the Netherlands Cancer Registry. The synchronous and metachronous detection of contralateral DCIS (cDCIS) and contralateral invasive breast cancer (cIBC) was assessed for patients who received an MRI upon diagnosis (MRI group) and for an age-matched control group without MRI. RESULTS: Nineteen percent of patients received an MRI, of which 0.8% was diagnosed with synchronous cDCIS and 1.3% with synchronous cIBC not found by mammography. The 5-year cumulative incidence of synchronous plus metachronous cDCIS was higher for the MRI versus age-matched control group (2.0% versus 0.9%, p = 0.02) and similar for cIBC (3.5% versus 2.3%, p = 0.17). The increased incidence of cDCIS was observed in patients aged < 50 years (sHR = 4.22, 95% CI: 1.19-14.99), but not in patients aged 50-74 years (sHR = 0.89, 95% CI: 0.41-1.93). CONCLUSIONS: MRI at primary DCIS diagnosis detected additional synchronous cDCIS and cIBC, and was associated with a higher rate of metachronous cDCIS without decreasing the rate of metachronous cIBC. This finding was most evident in younger patients. KEY POINTS: • Magnetic resonance imaging at primary diagnosis of ductal carcinoma in situ detected an additional synchronous breast lesion in 2.1% of patients. • In patients aged younger than 50 years, the use of pre-operative MRI was associated with a fourfold increase in the incidence of a second contralateral DCIS without decreasing the incidence of metachronous invasive breast cancers up to 5 years after diagnosis. • In patients aged over 50 years, the use of pre-operative MRI did not result in a difference in the incidence of a second contralateral DCIS or metachronous invasive breast cancer.

Effects of nonparticipation at previous screening rounds on the characteristics of screen-detected breast cancers.

PURPOSE: We determined the incidence and effects of different screening intervals prior to a true positive recall on the tumour characteristics of screen-detected cancers (SDC) and interval cancers (ICs) at biennial screening mammography. METHODS: A consecutive series of 553020 subsequent screens was included, obtained in a Dutch screening region between January 2009 and July 2019. During 2-year follow-up, we obtained data on radiological procedures, pathology and surgical interventions of all recalled women. RESULTS: A total of 13,221 women were recalled (2.4% recall rate), yielding 3662 women with a SDC (6.6 SDCs per 1000 screen). Of these, 3477 (94.9%) had attended their two most recent screens as scheduled (i.e., 2-year screening interval), whereas the interval between the two most recent screens was four years or at least six years in respectively 132 (3.6%) and 53 (1.4%) women. There was a trend of higher cancer detection rates in case of longer screening intervals. The proportions of DCIS versus invasive cancer, as well as tumour histology, tumour size, axillary lymph node status, B&R grading, hormone receptor status and type of surgical treatment (breast conserving surgery or mastectomy) were comparable for women with a 2-year or 4-year interval between their two latest screens. SDCs in women with at least six years between their two latest screens were more frequently estrogen receptor negative or triple negative and were more frequently treated by mastectomy. All tumour characteristics mentioned above were less favourable for ICs than SDCs. CONCLUSIONS: A vast majority of women with a SDC had a 2-year screening interval between their two latest screens. A screening interval of at least six years had a slight negative influence on the tumour characteristics and treatment of SDCs.

Failure of stereotactic core needle biopsy in women recalled for suspicious calcifications at screening mammography: frequency, causes, and final outcome in a multi-institutional, observational follow-up study.

OBJECTIVES: We determined the failure rate of stereotactic core needle biopsy (SCNB) and its causes and final outcome in women recalled for calcifications at screening mammography. METHODS: We included a consecutive series of 624,039 screens obtained in a Dutch screening region between January 2009 and July 2019. Radiology reports and pathology results were obtained of all recalled women during 2-year follow-up. RESULTS: A total of 3495 women (19.6% of 17,809 recalls) were recalled for suspicious calcifications. SCNB was indicated in 2818 women, of whom 12 had incomplete follow-up and another 12 women refused biopsy. DCIS or invasive cancer was diagnosed in 880 of the remaining 2794 women (31.5%). SCNB failed in 62 women (2.2%, 36/2794). These failures were mainly due to a too posterior (n = 30) or too superficial location (n = 17) of the calcifications or calcifications too faint for biopsy (n = 13). Of these 62 women, 10 underwent surgical biopsy, yielding one DCIS (intermediate grade) and two invasive cancers (one intermediate grade and one high grade) and another two women were diagnosed with DCIS (both high grade) at follow-up. Thus, the malignancy rate after SCNB failure was 8.1% (5/62). Calcifications were depicted neither at SCNB specimen radiography nor at pathology in 16 women after (repeated) SCNB (0.6%, 31/2732). None of them proved to have breast cancer at 2-year follow-up. CONCLUSIONS: The failure rate of SCNB for suspicious calcifications is low but close surveillance is warranted, as breast cancer may be present in up to 8% of these women. KEY POINTS: • The failure rate of stereotactic core needle biopsy (SCNB) for calcifications recalled at screening mammography was 2.2%. • Failures were mainly due to calcifications that could not be reached by SCNB or calcifications too faint for biopsy. • The management after failed SCNB was various. At least, close surveillance with a low threshold for surgical biopsy is recommended as breast cancer may be present in up to 8% of women with SCNB failure.

Added Value of Prereading Screening Mammograms for Breast Cancer by Radiologic Technologists on Early Screening Outcomes.

Background In the Dutch breast cancer screening program, mammograms are preread by technologists to identify possible abnormalities, leading to "warning signals" (an audible and visual alert if the technologist observed an abnormality suspicious for cancer) for radiologists. The best moment to present these warning signals is unknown. Purpose To determine the effect that blinding of technologists' warning signals has on radiologists' early screening outcome measures during interpretation of mammograms. Materials and Methods In this prospective study from September 2017 to May 2019, on alternating months, radiologists were either blinded or nonblinded to the warning signals of the technologist when interpreting screening mammograms for breast cancer. All discrepancies between radiologists and technologists were reviewed during quality assurance sessions every 6 weeks, which could result in secondary recalls. The outcome measures of this study were recall rate, cancer detection rate, and positive predictive value of recall. A χ2 test was used to test for differences between the two groups. Results During the study period, 109 596 women (mean age, 62 years ± 7 [standard deviation]), including 53 291 in the blinded and 56 305 in the nonblinded groups, participated. The overall recall rate (including secondary recalls) was lower for women in the blinded group than in the nonblinded group (blinded: 1140 of 53 291 women [2.1%], nonblinded: 1372 of 56 305 women [2.4%]; P = .001). There was no evidence of cancer detection rate differences between the groups (blinded: 349 of 53 291 women [6.5 per 1000 screening examinations], nonblinded: 360 of 56 305 women [6.4 per 1000 screening examinations]; P = .75). The blinded group thus had a higher positive predictive value of recall (blinded: 349 of 1140 women [30.6%], nonblinded: 360 of 1372 women [26.2%]; P = .02). Conclusion While interpreting screening mammograms for breast cancer, radiologists blinded to technologists' warning signals had lower recall rates with higher positive predictive values than nonblinded radiologists, yet cancer detection rates seemed to remain unchanged. See also the editorial by Hofvind and Lee in this issue. © RSNA, 2021.

The Impact of Preoperative Breast MRI on Surgical Margin Status in Breast Cancer Patients Recalled at Biennial Screening Mammography: An Observational Cohort Study.

BACKGROUND: This study aimed to examine the association between preoperative magnetic resonance imaging (MRI) and surgical margin involvement, as well as to determine the factors associated with positive resection margins in screen-detected breast cancer patients undergoing breast-conserving surgery (BCS). METHODS: Breast cancer patients eligible for BCS and diagnosed after biennial screening mammography in the south of The Netherlands (2008-2017) were retrospectively included. Missing values were imputed and multivariable regression analyses were performed to analyze whether preoperative MRI was related to margin involvement after BCS, as well as to examine what factors were associated with positive resection margins, defined as more than focally (>4 mm) involved. RESULTS: Overall, 2483 patients with invasive breast cancer were enrolled, of whom 123 (5.0%) had more than focally involved resection margins. In multivariable regression analyses, preoperative MRI was associated with a reduced risk of positive resection margins after BCS (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33-0.96). Lobular histology (adjusted OR 2.86, 95% CI 1.68-4.87), large tumor size (per millimeter increase, adjusted OR 1.05, 95% CI 1.03-1.07), high (>75%) mammographic density (adjusted OR 3.61, 95% CI 1.07-12.12), and the presence of microcalcifications (adjusted OR 4.45, 95% CI 2.69-7.37) and architectural distortions (adjusted OR 1.85, 95% CI 1.01-3.40) were independently associated with positive resection margins after BCS. CONCLUSIONS: Preoperative MRI was associated with lower risk of positive resection margins in patients with invasive breast cancer eligible for BCS using multivariable analysis. Furthermore, specific mammographic characteristics and tumor characteristics were independently associated with positive resection margins after BCS.

Patterns of treatment and outcome of ductal carcinoma in situ in the Netherlands.

PURPOSE: To spare DCIS patients from overtreatment, treatment de-escalated over the years. This study evaluates the influence of these developments on the patterns of care in the treatment of DCIS with particular interest in the use of breast conserving surgery (BCS), radiotherapy following BCS and the use and type of axillary staging. METHODS: In this large population-based cohort study all women, aged 50-74 years diagnosed with DCIS from January 1989 until January 2019, were analyzed per two-year cohort. RESULTS: A total of 30,417 women were diagnosed with DCIS. The proportion of patients undergoing BCS increased from 47.7% in 1995-1996 to 72.7% in 2017-2018 (p < 0.001). Adjuvant radiotherapy following BCS increased from 28.9% (1995-1996) to 89.6% (2011-2012) and subsequently decreased to 74.9% (2017-2018; p < 0.001). Since its introduction, the use of sentinel lymph node biopsy (SLNB) increased to 63.1% in 2013-2014 and subsequently decreased to 52.8% in 2017-2018 (p < 0.001). Axillary surgery is already omitted in 55.8% of the patients undergoing BCS nowadays. The five-year invasive relapse-free survival (iRFS) for BCS with adjuvant radiotherapy in the period 1989-2010, was 98.7% [CI 98.4% - 99.0%], compared to 95.0% [CI 94.1% -95.8%] for BCS only (p < 0.001). In 2011-2018, this was 99.3% [CI 99.1% - 99.5%] and 98.8% [CI 98.2% - 99.4%] respectively (p = 0.01). CONCLUSIONS: This study shows a shift toward less extensive treatment. DCIS is increasingly treated with BCS and less often followed by additional radiotherapy. The absence of radiotherapy still results in excellent iRFS. Axillary surgery is increasingly omitted in DCIS patients.

Frequency and diagnostic outcome of bilateral recall at screening mammography.

Our study was performed to determine the frequency of recall for bilateral breast lesions at screening mammography and compare its outcome with respect to unilateral recall. We included 329 132 screening mammograms (34 889 initial screens and 294 243 subsequent screens) from a Dutch screening mammography program between January 2013 and January 2018. During a 2-year follow-up, we collected radiological data, pathology reports and surgical reports of all recalled women. At bilateral recall, the lesion with the highest Breast Imaging Reporting and Data System score was used as the index lesion when comparing screening mammography characteristics at bilateral vs unilateral recall. A total of 9806 women were recalled at screening (recall rate, 3.0%). Bilateral recall comprised 2.8% (271/9806) of all recalls. Biopsy was more frequently performed after bilateral recall than unilateral recall (54.6% [148/271] vs 44.1% [4201/9535], P < .001), yielding a lower positive predictive value (PPV) of biopsy after bilateral recall (42.6% vs 51.7%, P = .029). The PPV of recall was comparable for both groups (23.2% [63/271] vs 22.8% [2173/9535], P = .85). Invasive cancers after bilateral recall were larger than those diagnosed after unilateral recall (P = .02), but histological subtype, histologic grading, receptor status and proportions of lymph node positive cancers were comparable. Bilateral recall infrequently occurs at screening mammography. Biopsy is more frequently performed following bilateral recall, but the PPV of recall is similar for unilateral and bilateral recall. Invasive cancers of both groups show comparable pathological features except of a larger tumor size after bilateral recall.

Delayed breast cancer diagnosis after repeated recall at biennial screening mammography: an observational follow-up study from the Netherlands.

BACKGROUND: Delay in detection of breast cancer may worsen tumour characteristics, with progression of tumour size and a higher risk of metastatic lymph nodes. The purpose of this study was to investigate delayed breast cancer diagnosis after repeated recall for the same mammographic abnormality at screening. METHODS: This was a retrospective study performed in two cohorts of women enrolled in a mammography screening programme in the Netherlands. All women aged 50-75 who underwent biennial screening mammography either between January 1, 1997 and December 31, 2006 (cohort 1) or between January 1, 2007 and December 31, 2016 (cohort 2) were included. RESULTS: The cohorts showed no difference in proportions of women with delayed breast cancer diagnosis of at least 2 years (2.2% versus 2.8%, P = 0.29). Most delays were caused by incorrect BI-RADS classifications after recall (74.2%). An increase in mean tumour size was seen when comparing sizes at initial false-negative recall and at diagnosis of breast cancer (P < 0.001). CONCLUSIONS: The proportion of women with a long delay in breast cancer confirmation following repeated recall at screening mammography has not decreased during 20 years of screening. These delays lead to larger tumour size at detection and may negatively influence prognosis.

Recall and Outcome of Screen-detected Microcalcifications during 2 Decades of Mammography Screening in the Netherlands National Breast Screening Program.

Background Trends in the detection of suspicious microcalcifications at mammography screening and the yield of these lesions after recall are unknown. Purpose To determine trends in recall and outcome of screen-detected microcalcifications during 20 years of mammography screening. Materials and Methods The authors performed a retrospective analysis of a consecutive series of 817 656 screening examinations (January 1997 to January 2017) in a national breast screening program. In 2009-2010 (transition period), screen-film mammography (SFM) was gradually replaced by full-field digital mammography (FFDM). The recalls of suspicious microcalcifications from all radiology reports and pathologic outcome of recalled women with 2-year follow-up were analyzed. Screening outcome in the era of SFM (1997-2008), the transition period (2009-2010), and the era of FFDM (2011-2016) were compared. Trends over time and variations between the SFM and FFDM periods were expressed by using proportions with 95% confidence intervals (CIs). In cases where the analysis based on the CI confirmed clear periods (eg, before and after introduction of FFDM), pre- and postchange outcomes were compared by using χ2 tests. Results A total of 18 592 women (median age, 59 years; interquartile range, 14 years) were recalled at mammography screening, 3556 of whom had suspicious microcalcifications. The recall rate for microcalcifications increased from 0.1% in 1997-1998 to 0.5% in 2015-2016 (P < .001). This was temporally associated with the change from SFM to FFDM. The recalls yielding ductal carcinoma in situ (DCIS) increased from 0.3 per 1000 screening examinations with SFM to 1.1 per 1000 screening examinations with FFDM (P < .001), resulting in a decrease in the positive predictive value for recall for suspicious microcalcifications from 51% to 33% (P < .001). More than half of all DCIS lesions were high grade (52.6%; 393 of 747). The distribution of DCIS grades was stable during the 20-year screening period (P = .36). Conclusion The recall rate for suspicious microcalcifications at mammographic screening increased during the past 2 decades, whereas the ductal carcinoma in situ detection rate increased less rapidly, resulting in a lower positive predictive value for recall. © RSNA, 2020.

Additional Breast Cancer Detection at Digital Screening Mammography through Quality Assurance Sessions between Technologists and Radiologists.

Background Screening technologists may function as readers in breast cancer screening programs. In the Netherlands, they attend quality assurance sessions. The frequency and characteristics of additional breast cancers detected through these sessions have not been reported. Purpose To determine the frequency and characteristics of cancers detected through quality assurance sessions. Materials and Methods This secondary analysis of a prospective cohort included 466 647 screening mammograms obtained between January 1, 2009, and January 1, 2017. Mammograms were single read by certified screening technologists before being double read by two certified screening radiologists who were not blinded to the technologists' reading. The technologists and a coordinating screening radiologist regularly discussed mammograms that the technologists considered suspicious but that did not prompt recall at radiologist double reading. The coordinating radiologist decided whether secondary recall was indicated. During a 2-year follow-up, radiologic and pathologic outcome data for all recalled women were obtained. Characteristics of cancers detected at radiologist double reading and those detected through quality assurance sessions were compared by using χ2 and Fisher exact tests. Results A total of 14 142 women (mean age, 59 years ± 7.8 [standard deviation]; range, 49-75 years) were recalled (recall rate, 3.0% [14 142 of 466 647]): 14 057 after radiologist double reading and 85 by the coordinating radiologists after quality assurance sessions. This resulted in 3156 screening-detected cancers (6.8 cancers detected per 1000 screenings), of which 26 (0.8% of screening-detected cancers [26 of 3156]) were detected after secondary recall through quality assurance sessions. The latter comprised eight ductal carcinomas in situ (88% intermediate or high grade [seven of eight]) and 18 invasive cancers (14 T1a-c and four T2+ cancers, 89% Nottingham grade I or II [16 of 18]). No significant differences in tumor characteristics were found (P values ranging from .22 to .95). Sensitivity of quality assurance sessions for additional cancer detection was 52% (26 of 50; 95% confidence interval: 38%, 66%). Conclusion The role of quality assurance sessions in additional cancer detection is limited. Tumor characteristics did not differ significantly from those of cancers detected at radiologist double reading. © RSNA, 2020.

Utility of diagnostic breast excision biopsies during two decades of screening mammography.

INTRODUCTION: We evaluated the use and value of breast surgical excision biopsies for diagnostic purposes over the last decades in women undergoing mammographic screening, either as a primary procedure or following an inconclusive percutaneous biopsy. METHODS: All women with an excision biopsy among 817,656 screens, obtained from January 1997 to January 2017, were included. RESULTS: Of 18,593 recalled women (recall rate, 2.3%) with screen-detected abnormalities, 908 (4.9%) underwent excision biopsy. Of these, 411 (45.3%) were performed as first diagnostic intervention, decreasing from 4.3 per 1000 screens in 1997-1998 to 0 per 1000 screens in 2015-2016. The remaining 497 (54.7%) excision biopsies were performed secondary to pathologic findings at percutaneous biopsy. During 1997-1998, 1.0 secondary biopsies per 1000 screens were performed, decreasing to 0.3 per 1000 in 2005-2006 and afterwards increased to 0.6 per 1000 in 2015-2016 (p = 0.003). Of all 487 secondary biopsies, 303 (61.0%) had a benign pathology outcome, increasing from 40.4% in 1997-1998 to 70.2% in 2015-2016. Of all 211 biopsies in the three most recent cohorts (2011-2016) the overall upgrade rate was 26.5%, consisting of 39 (18.5%) DCIS (27 low grade) and 17 (8.1%) invasive carcinomas. CONCLUSIONS: Although the use of excision biopsy significantly decreased over the past two decades, we observed a significant increased rate in more recent years. Since the vast majority of currently performed excision biopsies reveals a benign diagnosis or shows low grade DCIS, a secondary excision biopsy should only be considered if radiologic surveillance and repeated percutaneous biopsy continues to yield indeterminate results.

Utility of Supplemental Training to Improve Radiologist Performance in Breast Cancer Screening: A Literature Review.

PURPOSE: The authors evaluate whether supplemental training for radiologists improves their breast screening performance and how this is measured. METHODS: A systematic search was conducted in PubMed on August 3, 2017. Articles were included if they described supplemental training for radiologists reading mammograms to improve their breast screening performance and at least one outcome measure was reported. Study quality was assessed using the Medical Education Research Study Quality Instrument. RESULTS: Of 2,199 identified articles, 18 were included, of which 17 showed improvement on at least one of the outcome measures, for at least one training activity or subgroup. Two measurement approaches were found. For the first approach, measuring performance on test sets, sensitivity, and specificity were the most reported outcomes (8 of 11 studies). Recall rate is the most reported outcome (6 of 7 studies) for the second approach, which measures performance in actual screening practice. The studies were mainly of moderate quality (Medical Education Research Study Quality Instrument score 11.7 ± 1.7), caused by small sample sizes and the lack of a control group. CONCLUSIONS: Supplemental training helps radiologists improve their screening performance, despite the mainly moderate quality of the studies. There is a need for better designed studies. Future studies should focus on performance in actual screening practice and should look for methods to isolate the training effect. If test sets are used, focus should be on knowledge about correlation between performance on test sets and actual screening practice.

Trends in frequency and outcome of high-risk breast lesions at core needle biopsy in women recalled at biennial screening mammography, a multiinstitutional study.

Between January 1, 2011, and December 31, 2016, we studied the incidence, management and outcome of high-risk breast lesions in a consecutive series of 376,519 screens of women who received biennial screening mammography. During the 6-year period covered by the study, the proportion of women who underwent core needle biopsy (CNB) after recall remained fairly stable, ranging from 39.2% to 48.1% (mean: 44.2%, 5,212/11,783), whereas the proportion of high-risk lesions at CNB (i.e., flat epithelial atypia, atypical ductal hyperplasia, lobular carcinoma in situ and papillary lesions) gradually increased from 3.2% (25/775) in 2011 to 9.5% (86/901) in 2016 (p < 0.001). The mean proportion of high-risk lesions at CNB that were subsequently treated with diagnostic surgical excision was 51.4% (169/329) and varied between 41.0% and 64.3% through the years, but the excision rate for high-risk lesions per 1,000 screens and per 100 recalls increased from 0.25 (2011) to 0.70 (2016; p < 0.001) and from 0.81 (2011) to 2.50 (2016; p < 0.001), respectively. The proportion of all diagnostic surgical excisions showing in situ or invasive breast cancer was 29.0% (49/169) and varied from 22.2% (8/36) in 2014 to 38.5% (5/13) in 2011. In conclusion, the proportion of high-risk lesions at CNB tripled in a 6-year period, with a concomitant increased excision rate for these lesions. As the proportion of surgical excisions showing in situ or invasive breast cancer did not increase, a rising number of screened women underwent invasive surgical excision with benign outcome.

Correction to: Frequency and characteristics of contralateral breast abnormalities following recall at screening mammography.

The original version of this article, published on 17 April 2018, unfortunately contained a mistake.