Digital Mammography Has Persistently Increased High-Grade and Overall DCIS Detection Without Altering Upgrade Rate.

OBJECTIVE. The purpose of this article is to evaluate whether digital mammography (DM) is associated with persistent increased detection of ductal carcinoma in situ (DCIS) or has altered the upgrade rate of DCIS to invasive cancer. MATERIALS AND METHODS. An institutional review board-approved retrospective search identified DCIS diagnosed in women with mammographic calcifications between 2001 and 2014. Ipsilateral cancer within 2 years, masses, papillary DCIS, and patients with outside imaging were excluded, yielding 484 cases. Medical records were reviewed for mammographic calcifications, technique, and pathologic diagnosis. Mammograms were interpreted by radiologists certified by the Mammography Quality Standards Act. The institution transitioned from film-screen mammography (FSM) to exclusive DM by 2010. Statistical analyses were performed using chi-square test. RESULTS. Of 484 DCIS cases, 158 (33%) were detected by FSM and 326 (67%) were detected by DM. The detection rate was higher with DM than FSM (1.4 and 0.7 per 1000, respectively; p < .001). The detection rate of high-grade DCIS doubled with DM compared with FSM (0.8 and 0.4 per 1000, respectively; p < .001). The prevalent peak of DM-detected DCIS was 2.7 per 1000 in 2008. Incident DM detection remained double FSM (1.4 vs 0.7 per 1000). Similar proportions of high-grade versus low- to intermediate-grade DCIS were detected with both modalities. There was no significant difference in the upgrade rate of DCIS to invasive cancer between DM (10%; 34/326) and FSM (10%; 15/158) (p = .74). High-grade DCIS led to 71% (35/49) of the upgrades to invasive cancer. CONCLUSION. DM was associated with a significant doubling in DCIS and high-grade DCIS detection, which persisted after prevalent peak. The majority of upgrades to invasive cancer arose from high-grade DCIS. DM was not associated with decreased upgrade to invasive cancer.

Digital Breast Tomosynthesis Slab Thickness: Impact on Reader Performance and Interpretation Time.

Background Digital breast tomosynthesis (DBT) helps reduce recall rates and improve cancer detection compared with two-dimensional (2D) mammography but has a longer interpretation time. Purpose To evaluate the effect of DBT slab thickness and overlap on reader performance and interpretation time in the absence of 1-mm slices. Materials and Methods In this retrospective HIPAA-compliant multireader study of DBT examinations performed between August 2013 and July 2017, four fellowship-trained breast imaging radiologists blinded to final histologic findings interpreted DBT examinations by using a standard protocol (10-mm slabs with 5-mm overlap, 1-mm slices, synthetic 2D mammogram) and an experimental protocol (6-mm slabs with 3-mm overlap, synthetic 2D mammogram) with a crossover design. Among the 122 DBT examinations, 74 mammographic findings had final histologic findings, including 31 masses (26 malignant), 20 groups of calcifications (12 malignant), 18 architectural distortions (15 malignant), and five asymmetries (two malignant). Durations of reader interpretations were recorded. Comparisons were made by using receiver operating characteristic curves for diagnostic performance and paired t tests for continuous variables. Results Among 122 women, mean age was 58.6 years ± 10.1 (standard deviation). For detection of malignancy, areas under the receiver operating characteristic curves were similar between protocols (range, 0.83-0.94 vs 0.84-0.92; P ≥ .63). Mean DBT interpretation time was shorter with the experimental protocol for three of four readers (reader 1, 5.6 minutes ± 1.7 vs 4.7 minutes ± 1.4 [P < .001]; reader 2, 2.8 minutes ± 1.1 vs 2.3 minutes ± 1.0 [P = .001]; reader 3, 3.6 minutes ± 1.4 vs 3.3 minutes ± 1.3 [P = .17]; reader 4, 4.3 minutes ± 1.0 vs 3.8 minutes ± 1.1 [P ≤ .001]), with 72% reduction in both mean number of images and mean file size (P < .001 for both). Conclusion A digital breast tomosynthesis reconstruction protocol that uses 6-mm slabs with 3-mm overlap, without 1-mm slices, had similar diagnostic performance compared with the standard protocol and led to a reduced interpretation time for three of four readers. © RSNA, 2020 See also the editorial by Chang in this issue.

The Breast Radiologist as a Public Educator: Designing an Effective Presentation for a Lay Audience.

Educating the public about breast cancer screening and diagnosis is important. Medical and regulatory agencies encourage shared decision making about undergoing breast cancer screening, and there are many places women can get information and misinformation. The Internet and other media sources present information that may not be correct or understandable. Breast radiologists are uniquely qualified to provide women with the accurate information necessary to enable informed choices. As a specialty, we have an obligation to our community to provide relevant and understandable information. We can accomplish that through community outreach forums. Presentations should be understandable with plain language, focusing on our key message and using pertinent images or icons. Slides should be simple and avoid medical jargon or complex statistics. As we engage with the community, we provide a vital service to the health of our community and foster respect of our specialty.

Use of Screening Mammography to Detect Occult Malignancy in Autologous Breast Reconstructions: A 15-year Experience.

Purpose To examine how often screening mammography depicts clinically occult malignancy in breast reconstruction with autologous myocutaneous flaps (AMFs). Materials and Methods Between January 1, 2000, and July 15, 2015, the authors retrospectively identified 515 women who had undergone mammography of 618 AMFs and who had at least 1 year of clinical follow-up. Of the 618 AMFs, 485 (78.5%) were performed after mastectomy for cancer and 133 (21.5%) were performed after prophylactic mastectomy. Medical records were used to determine the frequency, histopathologic characteristics, presentation, time to recurrence, and detection modality of malignancy. Cancer detection rate (CDR), sensitivity, specificity, positive predictive value, and false-positive biopsy rate were calculated. Results An average of 6.7 screening mammograms (range, 1-16) were obtained over 15.5 years. The frequency of local-regional recurrence (LRR) was 3.9% (20 of 515 women; 95% confidence interval [CI]: 2.2%, 5.6%); all LRRs were invasive, and none were detected in the breast mound after prophylactic mastectomy. Of the 20 women with LRR, 13 (65%) were screened annually before the diagnosis. Seven of those 13 women (54%) had clinically occult LRR, and mammography depicted five. Five of the six clinically evident recurrences (83%) were interval cancers. The median time between reconstruction and first recurrence was 4.4 years (range, 0.8-16.2 years). The CDR per AMF was 1.5 per 1000 screening mammograms (five of 3358; 95% CI: 0.18, 2.8) after mastectomy for cancer and 0 of 1000 examinations (0 of 805 mammograms; 95% CI: 0, 5) after prophylactic mastectomy. Sensitivity, specificity, positive predictive value, and false-positive biopsy rate were 42% (five of 12), 99.4% (4125 of 4151), 16% (five of 31), and 0.6% (26 of 4151), respectively. Conclusion The CDR of screening mammography (1.5 per 1000 screening mammograms) of the AMF after mastectomy for cancer is comparable to that for one native breast of an age-matched woman. Screening mammography adds little value after prophylactic mastectomy. © RSNA, 2018.

Availability of prior mammograms affects incomplete report rates in mobile screening mammography.

PURPOSE: Mobile mammography can improve access to screening mammography in rural areas and underserved populations. We evaluated the frequency of incomplete reports in mobile mammography screening and the relationships between prior mammograms and recall rates. METHODS: The frequency of incomplete mammogram reports, the subgroups of those needing prior comparison mammograms, recalls for additional imaging, and availability of prior mammograms of a mobile screening mammography unit were compared with fixed site mammography from January 1, 2007 through December 31, 2009. All mobile unit mammograms were full field digital mammography (FFDM). Differences between rates of recall, incomplete reports, and availability of prior mammograms were calculated using the Chi-Square statistic. RESULTS: Of 2640 mobile mammography cases, 21.9% (578) reports were incomplete, versus 15.2% (7653) (p ≤ 0.001) of 50325 fixed site reports. Of incomplete cases, recall for additional imaging occurred among 8.3% (218) of mobile mammography reports versus 11.3% (5708) (p ≤ 0.001) of fixed site reports. Prior mammograms were needed among 13.6% (360) of mobile mammography versus 3.9% (1945) (p ≤ 0.001) of fixed site reports. Mobile mammography recall rate varied with availability of prior mammograms: 16.0% (54) when no prior mammograms, 7.6% (127) when prior mammograms were elsewhere but unavailable and 5.9% (37) when prior FFDM were immediately available (p ≤ 0.001). CONCLUSIONS: Incomplete reports were more frequent in mobile mammography than the fixed site. The availability of prior comparison mammograms at time of interpretation decreased the rate of incomplete mammogram reports. Recall rates were higher without prior comparison mammograms and lowest when comparison FFDM mammograms were available.

Harms of Restrictive Risk-Based Mammographic Breast Cancer Screening.

OBJECTIVE: The objective of this study was to determine if restrictive risk-based mammographic screening could miss breast cancers that population-based screening could detect. MATERIALS AND METHODS: Through a retrospective search of records at a single institution, we identified 552 screen-detected breast cancers in 533 patients. All in situ and invasive breast cancers detected at screening between January 1, 2011, and December 31, 2014, were included. Medical records were reviewed for history, pathology, cancer size, nodal status, breast density, and mammographic findings. Mammograms were interpreted by one of 14 breast imaging radiologists with 3-30 years of experience, all of whom were certified according to the Mammography Quality Standards Act. Patient ages ranged from 36 to 88 years (mean, 61 years). The breast cancer risks evaluated were family history of breast cancer and dense breast tissue. Positive family history was defined as a first-degree relative with breast cancer. Dense breast parenchyma was either heterogeneously or extremely dense. RESULTS: Group 1 consisted of the 76.7% (409/533) of patients who had no personal history of breast cancer. Of these patients, 75.6% (309/409) had no family history of breast cancer, and 56% (229/409) had nondense breasts. Group 2 consisted of the 16.7% (89/533) of patients who were 40-49 years old. Of these patients, 79.8% (71/89) had no family history of breast cancer, and 30.3% (27/89) had nondense breasts. Ductal carcinoma in situ made up 34.6% (191/552) of the cancers; 65.4% (361/552) were invasive. The median size of the invasive cancers was 11 mm. Of the screen-detected breast cancers, 63.8% (352/552) were minimal cancers. CONCLUSION: Many screen-detected breast cancers occurred in women without dense tissue or a family history of breast cancer. Exclusive use of restrictive risk-based screening could result in delayed cancer detection for many women.

Surgical biopsy is still necessary for BI-RADS 4 calcifications found on digital mammography that are technically too faint for stereotactic core biopsy.

The purpose of this study was to evaluate the outcome of faint BI-RADS 4 calcifications detected with digital mammography that were not amenable to stereotactic core biopsy due to suboptimal visualization. Following Institutional Review Board approval, a HIPAA compliant retrospective search identified 665 wire-localized surgical excisions of calcifications in 606 patients between 2007 and 2010. We included all patients that had surgical excision for initial diagnostic biopsy due to poor calcification visualization, whose current imaging was entirely digital and performed at our institution and who did not have a diagnosis of breast cancer within the prior 2 years. The final study population consisted of 20 wire-localized surgical biopsies in 19 patients performed instead of stereotactic core biopsy due to poor visibility of faint calcifications. Of the 20 biopsies, 4 (20% confidence intervals 2, 38%) were malignant, 5 (25%) showed atypia and 11 (55%) were benign. Of the malignant cases, two were invasive ductal carcinoma (2 and 1.5 mm), one was intermediate grade DCIS and one was low-grade DCIS. Malignant calcifications ranged from 3 to 12 mm. The breast density was scattered in 6/19 (32%), heterogeneously dense in 11/19 (58%) and extremely dense in 2/19 (10%). Digital mammography-detected faint calcifications that were not amenable to stereotactic biopsy due to suboptimal visualization had a risk of malignancy of 20%. While infrequent, these calcifications should continue to be considered suspicious and surgical biopsy recommended.

Outcomes of solid palpable masses assessed as BI-RADS 3 or 4A: a retrospective review.

The purpose of this study was to evaluate the outcomes and cancer rate in solid palpable masses with benign features assessed as BI-RADS 3 or 4A. This study was Institutional Review Board approved. Mammography and breast ultrasound reports in our Radiology Information System were searched for solid, palpable masses with benign features described from 1/1/2000 to 12/31/2009, and retrospectively reviewed. Those masses prospectively assessed as BI-RADS 3 or 4A, or suggestive of a fibroadenoma or other benign pathology were retrieved. Chart review was used to assess outcomes and cancer rate. Basic summary measures were summarized and compared between BI-RADS 3 and 4A groups using Wilcoxon Rank Sum test for continuous data or Fisher's exact test for categorical data. The cancer rate across age quartiles was assessed using Cochran-Armitage trend test. 573 solid palpable masses with benign features in 487 women were identified. There were 197 BI-RADS 3 and 376 BI-RADS 4A masses. The overall cancer rate was 1.6 % (9/573). All cancers were BI-RADS 4A (cancer rate 2.4 %-9/376). Smaller mean size and younger age at presentation in BI-RADS 3 women was found compared to BI-RADS 4A (P < 0.0001). There was a significant increase in cancer rate across age quartiles (P = 0.03124). The cancer rate is very low in solid palpable masses with benign features. In particular, BI-RADS 3 palpable masses in young women may undergo close surveillance without immediate biopsy, confirming what other investigators have found. All cancers were in the BI-RADS 4A group with increasing incidence with age, with over half occurring in women over 40 years old. Palpable masses in women 40 and older with benign features should be considered for immediate biopsy.

Does digital mammography increase detection of high-risk breast lesions presenting as calcifications?

OBJECTIVE: The objective of our study was to evaluate whether the transition from film-screen mammography (FSM) to digital mammography (DM) was associated with increased detection of high-risk breast lesions. MATERIALS AND METHODS: A retrospective search identified 142 cases of atypia or lobular neoplasia (LN) diagnosed in women with mammographic calcifications between January 2004 and August 2010. We excluded lesions upgraded to cancer at excisional biopsy, lesions in women with ipsilateral cancer within 2 years of mammography, and lesions that presented as a mass only. The cases included in the cohort were 82 (57.7%) cases of atypical ductal hyperplasia; 17 (12%) atypical lobular hyperplasia; 25 (17.6%) lobular carcinoma in situ (LCIS); 12 (8.5%) atypia and LCIS; and six (4.2%) other atypia. The institution transitioned from predominantly performing FSM in 2004 to performing only DM by 2010. Pathology was interpreted by breast pathologists. The annual detection rate was calculated by dividing the number of high-risk lesions by mammography volume. RESULTS: Of the 142 cases of atypia or LN, 52 (36.6%) were detected using FSM and 90 (63.4%) were detected using DM. The detection rate was higher with DM (1.24/1000 mammographic studies) than FSM (0.37/1000 mammographic studies). The detection rate by year ranged between 0.21 and 0.64 per 1000 mammographic studies for FSM and between 0.32 and 1.49 per 1000 mammographic studies for DM. The median size of the calcifications was 8 mm on DM and 7 mm on FSM. The most common appearance was clustered amorphous or indistinct calcifications on both FSM and DM. CONCLUSION: The transition from FSM to DM was associated with a threefold increase in the detection rate of high-risk lesions. Improved detection may allow enhanced screening, risk reduction treatment, and possibly breast cancer prevention. However, increased detection of high-risk lesions may also result in oversurveillance and treatment.

Adherence to screening mammography among American Indian women of the Northern Plains.

Breast cancer is a burden for American Indian (AI) women who have younger age at diagnosis and higher stage of disease. Rural areas also have had less access to screening mammography. An Indian Health Service Mobile Women's Health Unit (MWHU) was implemented to improve mammogram screening of AI women in the Northern Plains. Our purpose was to determine the past adherence to screening mammography at a woman's first presentation to the MWHU for mammogram screening. Date of the most recent prior non-MWHU mammogram was obtained from mammography records. Adherence to screening guidelines was defined as the prior mammogram occurring 1-2 years before the first MWHU visit among women >41 years, and was the main outcome, whereas, age and clinic site were predictors. Adherence was compared with national data of the Breast Cancer Surveillance Consortium (BCSC). Among 1,771 women >41 years, adherence to screening mammography guidelines was 48.01 % among >65 years, 42.05 % among 50-64 years, 33.43 % among 41-49 years, and varied with clinic site (25.23-65.93 %). Age (p < 0.0001) and clinic site (p < 0.0001) were associated with adherence. Overall, adherence to screening mammography guidelines was found in 39.86 % (706/1771) of MWHU women versus 74.34 % (747,095/1,004,943) of BCSC women. The majority (60.14 %) of women at first presentation to the MWHU had not had mammograms in the previous 2 years, lower screening adherence than nationally (25.66 %). Adherence was lowest among women ages 41-49, and varied with clinic site. Findings suggest disparities in mammography screening among these women.

Breast mass characterization using 3-dimensional automated ultrasound as an adjunct to digital breast tomosynthesis: a pilot study.

OBJECTIVES: The purpose of this study was to retrospectively evaluate the effect of 3-dimensional automated ultrasound (3D-AUS) as an adjunct to digital breast tomosynthesis (DBT) on radiologists' performance and confidence in discriminating malignant and benign breast masses. METHODS: Two-view DBT (craniocaudal and mediolateral oblique or lateral) and single-view 3D-AUS images were acquired from 51 patients with subsequently biopsy-proven masses (13 malignant and 38 benign). Six experienced radiologists rated, on a 13-point scale, the likelihood of malignancy of an identified mass, first by reading the DBT images alone, followed immediately by reading the DBT images with automatically coregistered 3D-AUS images. The diagnostic performance of each method was measured using receiver operating characteristic (ROC) curve analysis and changes in sensitivity and specificity with the McNemar test. After each reading, radiologists took a survey to rate their confidence level in using DBT alone versus combined DBT/3D-AUS as potential screening modalities. RESULTS: The 6 radiologists had an average area under the ROC curve of 0.92 for both modalities (range, 0.89-0.97 for DBT and 0.90-0.94 for DBT/3D-AUS). With a Breast Imaging Reporting and Data System rating of 4 as the threshold for biopsy recommendation, the average sensitivity of the radiologists increased from 96% to 100% (P > .08) with 3D-AUS, whereas the specificity decreased from 33% to 25% (P > .28). Survey responses indicated increased confidence in potentially using DBT for screening when 3D-AUS was added (P < .05 for each reader). CONCLUSIONS: In this initial reader study, no significant difference in ROC performance was found with the addition of 3D-AUS to DBT. However, a trend to improved discrimination of malignancy was observed when adding 3D-AUS. Radiologists' confidence also improved with DBT/3DAUS compared to DBT alone.

Ensuring excision of intraductal lesions: marker placement at time of ductography.

RATIONALE AND OBJECTIVES: To propose grid coordinate marker placement for patients with suspicious ductogram findings occult on routine workup. To compare the success of marker placement and wire localization (WL) with ductogram-guided WL. MATERIALS AND METHODS: A retrospective search of radiology records identified all patients referred for ductography between January 2001 and May 2008. Results for 16 patients referred for ductogram-guided WL and 5 patients with grid coordinate marker placement at the time of ductography and subsequent WL were reviewed. Surgical pathology results and clinical follow-up were reviewed for concordance. RESULTS: Nine of 16 patients (56.3%) underwent successful ductogram-guided WL. Eight of nine patients had papillomas, one of which also had atypical ductal hyperplasia (ADH). One of nine patients had ectatic ducts with inspisated debris. Seven patients who failed ductogram-guided WL eventually underwent open surgical biopsy. Four of seven patients had papillomas, one of which also had lobular carcinoma in situ. Remaining patients had ADH (1/7) and fibrocystic changes with chronic inflammation (3/7). All five (100%) patients with grid coordinate marker placement underwent successful WL and marker excision. Pathology results included three papillomas, papillary intraductal hyperplasia, and fibrocystic change. CONCLUSION: Grid coordinate marker placement at the time of abnormal ductogram provided an accurate method of localizing ductal abnormalities that are occult on routine workup, thus facilitating future WL. Marker placement obviated the need for repeat ductogram on the day of surgery and ensured surgical removal of the ductogram abnormality.

Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings.

BACKGROUND: Sonography is usually requested to evaluate palpable pediatric breast lumps, and solid masses are almost always fibroadenomas. Lack of familiarity with the findings of fibroadenomas can lead to diagnostic uncertainty and sometimes unnecessary biopsy and excision. We sought to review the spectrum of sonographic findings in our cases of pathology proven pediatric fibroadenomas. OBJECTIVE: The purpose of this retrospective study was to describe the sonographic appearances of pathologically proven pediatric breast fibroadenomas. MATERIALS AND METHODS: A query of the Department of Radiology database at our institution was performed for all patients younger than 19 years who underwent breast US from January 2001 to June 2009. A total of 332 patients were identified: 282 girls (85%) and 50 boys (15%). Ninety-one girls and no boys had a solid breast mass based on US findings. Forty-three children had a total of 49 pathologically proven breast masses with the diagnoses of fibroadenoma (44), hamartoma (1), non-Hodgkin lymphoma (1), tubular adenoma (1), pseudoangiomatous stromal hyperplasia (1) and lactation changes (1). Reviews of medical records, histological results and sonographic examinations of all pathology-proven fibroadenomas were performed. US findings were characterized according to location, multiplicity, size, shape, echogenicity and homogeneity, definition of margins, posterior acoustic features and Doppler vascularity. RESULTS: The vast majority of solid breast masses in girls are histologically benign. Fibroadenomas accounted for 91% of the pathologically proven solid breast masses. Common findings on US imaging are an oval shape, hypoechoic echo pattern, posterior acoustic enhancement and internal Doppler signal. Lobulations were found in 57% of the masses. Less common findings are absent internal vascular flow and complex echo pattern, while isoechoic echo pattern, posterior shadowing and angular margins are rare or unusual. CONCLUSION: Fibroadenomas represent the most common solid mass in the breasts of girls. Sonographic appearances are usually characteristic and do not significantly differ from those found in adults. The radiologist must be aware of common and uncommon sonographic appearances of fibroadenomas in the pediatric age group and should be cautious when recommending histological confirmation based on imaging findings, as breast malignancy is extremely rare.

Sonographically-guided metallic marker placement at time of wire localization for intraductal or cystic lesions: a method to verify lesion retrieval.

RATIONALE AND OBJECTIVES: To propose deploying a metallic marker using sonographic guidance immediately before wire localization for excisional biopsy to identify intraductal or complex cystic lesions at specimen radiography. MATERIALS AND METHODS: Institutional review board approval was obtained for this study and is Health Insurance Portability and Accountability Act compliant. The clinical, radiographic, and pathologic records of 21 patients, ages 21-78 years, with 22 intraductal or complex cystic masses who underwent excisional biopsy with wire localization immediately after sonographically-guided marker placement were reviewed. The procedure mammogram, ultrasound, and specimen radiographs were reviewed and evaluated for the presence of a metallic marker, lesion, or both. Pathology of all specimens was recorded and reviewed for concordance. RESULTS: Twenty-one (95%) of the markers were visualized on specimen radiographs. No lesions were apparent on specimen radiographs. Mammographic findings in 17 were negative (17/22; 77%); 3 circumscribed or partially obscured masses (3/22; 14%), 1 focal asymmetry (1/22; 5%), and 1 architectural distortion (5%) were also seen. Sonographic findings were 12 intraductal masses (12/22; 55%) and 10 complex cystic masses (10/22; 45%). Median and average size of all lesions were 9 mm (intraductal masses: median, 6 mm, mean, 7; complex cystic masses: median, 10 mm, mean, 11). All lesions were benign and all pathology was concordant with imaging findings. CONCLUSIONS: Given the high rate of marker retrieval on specimen radiography and pathologic concordance, marker placement at the time of wire localization is an efficient way to confirm retrieval of intraductal or complex cystic lesions.

Costs of achieving high patient compliance after recall from screening mammography.

OBJECTIVE: The purpose of our study was to document the hidden costs in achieving high recall patient compliance from an off-site screening mammography program. MATERIALS AND METHODS: This study was approved by our institutional review board. At our institution, no patient was placed in final BI-RADS assessment category 3, 4, or 5 without a diagnostic study. Each incomplete study, in addition to the formal report, was flagged on the day sheet, letters were sent to the referring physician and patient, and an incomplete computer code was added. Working from the day sheets, a clerk contacted the patient by telephone within 2 working days to schedule the diagnostic study. Diagnostic slots were purposely left open to accommodate these cases. An ongoing computer tickler file of incomplete codes provided a further check. A time study of clerical performance with recalled patients was measured prospectively for 100 consecutive cases. RESULTS: For the years 2002-2004, 4,025 (13%) of 30,286 screening patients were recalled for diagnostic mammography. After an average of 2.2 telephone calls per patient, (3.64 minutes of clerical time), 3,977 of 4,005 patients returned for a diagnostic study. Forty-eight of 4,025 initially noncompliant patients received an average of six telephone calls (4.7 minutes) and a registered letter. One of the 28 initially noncompliant patients went on to biopsy that revealed a breast cancer. Patient compliance was 4,005 (99.5%) of 4,025. The additional cost for this program was $4,724 divided by 30,286 screening patients, or 16 cents per screening patient. CONCLUSION: The radiology department assumed responsibility for contacting patients who needed recall for additional diagnostic imaging. Using strict documentation of the incomplete breast imaging evaluations, computer checks, clerical support, and prompt scheduling, we achieved 99.5% compliance. The additional cost was small, 16 cents per screening patient.