Surveillance for second breast cancer events in women with a personal history of breast cancer using breast MRI: a systematic review and meta-analysis.

PURPOSE: Women with personal history of breast cancer (PHBC) are currently recommended to receive annual mammography for surveillance of breast cancer recurrence or new primary. However, given issues in accuracy with mammography, there is a need for evolving evidence-based surveillance recommendations with supplemental imaging. In this systematic review, we compiled and compared existing studies that describe the test performance of surveillance breast MRI among women with PHBC. METHODS: We searched PubMed and EMBASE using MeSH terms for studies (2000-2019) that described the diagnostic characteristics of breast MRI in women with PHBC. Search results were reviewed and included based on PICOTS criteria; quality of included articles was assessed using QUADAS-2. Meta-analysis of single proportions was conducted for diagnostic characteristics of breast MRI, including tests of heterogeneity. RESULTS: Our review included 11 articles in which unique cohorts were studied, comprised of a total of 8338 women with PHBC and 12,335 breast MRI done for the purpose of surveillance. We predict intervals (PI) for cancer detection rate per 1000 examinations (PI 9-15; I2 = 10%), recall rate (PI 5-31%; I2 = 97%), sensitivity (PI 58-95%; I2 = 47%), specificity (PI 76-97%; I2 = 97%), and PPV3 (PI 16-40%; I2 = 44%). CONCLUSIONS: Studies addressing performance of breast MRI are variable and limited in population-based studies. The summary of evidence to date is insufficient to recommend for or against use of breast MRI for surveillance among women with PHBC.

Patterns of Breast Imaging Use Among Women with a Personal History of Breast Cancer.

BACKGROUND: National patterns of breast imaging in women with a personal history of breast cancer (PHBC) are unknown making evaluation of annual surveillance recommendations a challenge. OBJECTIVE: To describe variation in use of mammography and breast magnetic resonance imaging (MRI) examinations beginning 6 months after diagnosis among women with PHBC in US community practice. We report on the breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type. DESIGN: Longitudinal study using cross-sectional data. SETTING: Breast Cancer Surveillance Consortium breast imaging facilities. PARTICIPANTS: 19,955 women diagnosed between 2005 and 2012 with AJCC stage 0-III incident breast cancer who had 69,386 mammograms and 3,553 breast MRI examinations from January 2005 to September 2013; median follow-up of 37.6 months (interquartile range, 22.1-60.7). MAIN MEASURES: Breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type. KEY RESULTS: Among women with a PHBC who received breast imaging, 89.4% underwent mammography alone, 0.8% MRI alone, and 10.3% had both mammography and MRI. About half of mammograms and MRIs were indicated for surveillance vs. diagnostic, with an increase in the proportion of surveillance exams as time from diagnosis increased (mammograms, 45.7% at 1 year to 72.2% after 5 years; MRIs, 54.8% at 1 year to 78.6% after 5 years). In the first post-diagnosis period, 32.8% of women had > 2 breast imaging examinations and of these, 65.8% were less than 6 months apart. During the first 5-year post-diagnosis, the frequency of examinations per year decreased and the interval between examinations shifted towards annual examinations. CONCLUSION: In women with a PHBC who received post-diagnosis imaging, a third underwent multiple breast imaging examinations per year during the first 2-year post-diagnosis despite recommendations for annual exams. As time since diagnosis increases, imaging indication shifts from diagnostic to surveillance.

Surveillance Breast MRI and Mammography: Comparison in Women with a Personal History of Breast Cancer.

Background There is lack of consensus regarding the use of breast MRI for routine surveillance for second breast cancer events in women with a personal history of breast cancer. Purpose To compare performance of surveillance mammography with breast MRI. Materials and Methods This observational cohort study used prospectively collected data and included 13 266 women age 18 years and older (mean age, 60 years ± 13) with stage 0-III breast cancer who underwent 33 938 mammographic examinations and 2506 breast MRI examinations from 2005 to 2012 in the Breast Cancer Surveillance Consortium. Women were categorized into two groups: mammography alone (n = 11 745) or breast MRI (n = 1521). Performance measures were calculated by using end-of-day assessment and occurrence of second breast cancer events within 1 year of imaging. Logistic regression was used to compare performance for breast MRI versus mammography alone, adjusting for women, examination, and primary breast cancer characteristics. Analysis was conducted on a per-examination basis. Results Breast MRI was associated with younger age at diagnosis, chemotherapy, and higher education and income. Raw performance measures for breast MRI versus mammography were as follows, respectively: cancer detection rates, 10.8 (95% confidence interval [CI]: 6.7, 14.8) versus 8.2 (95% CI: 7.3, 9.2) per 1000 examinations; sensitivity, 61.4% (27 of 44; 95% CI: 46.5%, 76.2%) versus 70.3% (279 of 397; 95% CI: 65.8%, 74.8%); and biopsy rate, 10.1% (253 of 2506; 95% CI: 8.9%, 11.3%) versus 4.0% (1343 of 33 938; 95% CI: 3.7%, 4.2%). In multivariable models, breast MRI was associated with higher biopsy rate (odds ratio [OR], 2.2; 95% CI: 1.9, 2.7; P < .001) and cancer detection rate (OR, 1.7; 95% CI: 1.1, 2.7; P = .03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI: 0.4, 2.9; P = .84) or interval cancer rate (OR, 1.1; 95% CI: 0.6, 2.2; P = .70). Conclusion Comparison of the performance of surveillance breast MRI with mammography must account for patient characteristics. Whereas breast MRI leads to higher biopsy and cancer detection rates, there were no significant differences in sensitivity or interval cancers compared with mammography. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Newell in this issue.

Women's experiences and preferences regarding breast imaging after completing breast cancer treatment.

BACKGROUND: After treatment for breast cancer, most women receive an annual surveillance mammography to look for subsequent breast cancers. Supplemental breast MRI is sometimes used in addition to mammography despite the lack of clinical evidence for it. Breast imaging after cancer treatment is an emotionally charged experience, an important part of survivorship care, and a topic about which limited patient information exists. We assessed women's experiences and preferences about breast cancer surveillance imaging with the goal of determining where gaps in care and knowledge could be filled. PARTICIPANTS AND METHODS: We conducted six focus groups with a convenience sample of 41 women in California, North Carolina, and New Hampshire (USA). Participants were aged 38-75 years, had experienced stage 0-III breast cancer within the previous 5 years, and had completed initial treatment. We used inductive thematic analysis to identify key themes from verbatim transcripts. RESULTS: Women reported various types and frequencies of surveillance imaging and a range of surveillance imaging experiences and preferences. Many women experienced discomfort during breast imaging and anxiety related to the examination, primarily because they feared subsequent cancer detection. Women reported trust in their providers and relied on providers for imaging decision-making. However, women wanted more information about the treatment surveillance transition to improve their care. CONCLUSION: There is significant opportunity in breast cancer survivorship care to improve women's understanding about breast cancer surveillance imaging and to provide enhanced support to them at the time their initial treatment ends and at the time of surveillance imaging examinations.

The patient voice in research-evolution of a role.

PLAIN ENGLISH SUMMARY: Engaging patients in research studies is becoming more common because it makes research and its results more relevant for patients. It is important to understand the best ways for patients and researchers to work together. Patients who are included as active partners in research can provide useful input on what it is like to work on a research team but very little has been written about this from the patient's perspective. As patient partners and researchers on a breast cancer study, we share our experience to develop a patient-centered project and the inclusion of patient collaborators as scientific experts. Over time, the role of the patient partner has developed to include unanticipated roles and responsibilities. We use our experience to share how the patient voice can affect the execution of a research study and to provide a model for meaningfully engaging patients in research. ABSTRACT: Engaging patients in research studies is becoming more common because it makes research and its results more relevant for patients. It is important to understand the best ways for patients and researchers to work together. Patients who are included as active partners in research can provide useful input on what it is like to work on a research team but very little has been written about this from the patient's perspective. As patient partners and researchers on a breast cancer study, we share our experience to develop a patient-centered project and the inclusion of patient collaborators as scientific experts. Over time, the role of the patient partner has developed to include unanticipated roles and responsibilities. We use our experience to share how the patient voice can affect the execution of a research study and to provide a model for meaningfully engaging patients in research.

Forensic bitemark identification: weak foundations, exaggerated claims.

Several forensic sciences, especially of the pattern-matching kind, are increasingly seen to lack the scientific foundation needed to justify continuing admission as trial evidence. Indeed, several have been abolished in the recent past. A likely next candidate for elimination is bitemark identification. A number of DNA exonerations have occurred in recent years for individuals convicted based on erroneous bitemark identifications. Intense scientific and legal scrutiny has resulted. An important National Academies review found little scientific support for the field. The Texas Forensic Science Commission recently recommended a moratorium on the admission of bitemark expert testimony. The California Supreme Court has a case before it that could start a national dismantling of forensic odontology. This article describes the (legal) basis for the rise of bitemark identification and the (scientific) basis for its impending fall. The article explains the general logic of forensic identification, the claims of bitemark identification, and reviews relevant empirical research on bitemark identification-highlighting both the lack of research and the lack of support provided by what research does exist. The rise and possible fall of bitemark identification evidence has broader implications-highlighting the weak scientific culture of forensic science and the law's difficulty in evaluating and responding to unreliable and unscientific evidence.

Complex layered dental restorations: Are they recognizable and do they survive extreme conditions?

Recent research has shown that restorative dental materials can be recognized by microscopy and elemental analysis (scanning electron microscopy/energy dispersive X-ray spectroscopy and X-ray fluorescence; SEM/EDS and XRF) and that this is possible even in extreme conditions, such as cremation. These analytical methods and databases of dental materials properties have proven useful in DVI (disaster victim identification) of a commercial plane crash in 2009, and in a number of other victim identification cases. Dental materials appear on the market with ever expanding frequency. With their advent, newer methods of restoration have been proposed and adopted in the dental office. Methods might include placing multiple layers of dental materials, where they have different properties including adhesion, viscosity, or working time. These different dental materials include filled adhesives, flowable resins, glass ionomer cements, composite resins, liners and sealants. With possible combinations of different materials in these restorations, the forensic odontologist is now confronted with a new difficulty; how to recognize each individual material. The question might be posed if it is even possible to perform this task. Furthermore, an odontologist might be called upon to identify a victim under difficult circumstances, such as when presented with fragmented or incinerated remains. In these circumstances the ability to identify specific dental materials could assist in the identification of the deceased. Key to use of this information is whether these new materials and methods are detailed in the dental chart. Visual or radiographic inspection may not reveal the presence of a restoration, let alone the possible complex nature of that restoration. This study demonstrates another scientific method in forensic dental identification.

Distortion in fingerprints: a statistical investigation using shape measurement tools.

Friction ridge impression appearance can be affected due to the type of surface touched and pressure exerted during deposition. Understanding the magnitude of alterations, regions affected, and systematic/detectable changes occurring would provide useful information. Geometric morphometric techniques were used to statistically characterize these changes. One hundred and fourteen prints were obtained from a single volunteer and impressed with heavy, normal, and light pressure on computer paper, soft gloss paper, 10-print card stock, and retabs. Six hundred prints from 10 volunteers were rolled with heavy, normal, and light pressure on soft gloss paper and 10-print card stock. Results indicate that while different substrates/pressure levels produced small systematic changes in fingerprints, the changes were small in magnitude: roughly the width of one ridge. There were no detectable changes in the degree of random variability of prints associated with either pressure or substrate. In conclusion, the prints transferred reliably regardless of pressure or substrate.

Shape measurement tools in footwear analysis: a statistical investigation of accidental characteristics over time.

Presence of accidental characteristics on footwear strengthens the linkage of a given piece of footwear to a footwear impression left at a crime-scene. Thus an understanding of rate of appearance and disappearance of these characteristics is of importance. Artificial cut-marks, 1-3mm in depth, were cut into outsoles of 11 pairs of athletic shoes. Loss of these cut-marks and acquisition of new accidental characteristics/wear patterns were monitored over a seven-week time-span. Feature-vector methods were used to acquire multivariate data on wear/acquisition rates. A repeatability study indicated the feature vector method could detect small differences among shoes relative to measurement uncertainty. The shoes displayed a strong retention of artificial cut-marks over the study interval. Net rate of wear was 0.1% of the textured area of the shoe per week, predominantly in the heel and ball area. Results indicate accidental characteristics can reasonably be expected to persist over time.

Effect of systematic dental shape modification in bitemarks.

Studies on human cadaver models have reported significant levels of distortion of bitemarks in skin, indicating that tooth characteristics are not reliably transferred and recorded in the bitten subject. Moreover, matches among the anterior biting dentition in open population studies have been found. This prompts the question as to what degree of difference in shape will distinguish one dentition from another as reflected in a bitemark. In order to understand how these variables appear on skin, 10 dental casts with systematic variations in tooth positions were produced. The height of the lateral incisors was systematically altered in 1mm increments up to 3mm and lateral incisor/canines were altered in facial/lingual displacement in 1mm increments up to 5mm. Each of the models was used to produce a series of 10 repeated bites, distributed over arms and legs of un-embalmed cadavers. Landmark-based geometric morphometrics were used for analysis of digital images of the bitemarks. Results indicate that alterations of height and displacement of particular teeth affected the position of impressions created by the adjacent teeth. Displacement of one lateral incisor/canine led to a relative shift in impressions of the central incisors and unaltered canines, while height alteration of the lateral incisors led to a shift in relative position of central incisors as recorded in the bitemark. The prominence of displacements was more pronounced in the bitemarks than in images of the dentition used to make the bites, thus the bitemarks tended to exaggerate the differences. It was found that a displacement of 5mm between teeth allowed for reliable distinction between bitemarks. No such threshold of distinction could be established for differences in height of teeth under these experimental conditions. The effect of distortion was more significant in the mandibular than maxillary arch, suggesting that the mandible exhibits higher variation than the maxilla, as impressed in skin. Numerous bitemarks also exhibited arch flattening, consistent with recent studies showing arch width as the principal variable in a bitemark.

Patterns of variation and match rates of the anterior biting dentition: characteristics of a database of 3D-scanned dentitions.

An understanding of the variability of the anterior human dentition is essential in bitemark analysis. A collection of 1099 3D laser scans of paired maxillary and mandibular arches were studied using geometric morphometric methods. Analyses were performed without scale (shape only) and with scale (shape and size). Specimens differing by no more than experimentally obtained measurement error were counted as matches, or as indistinguishable. A total of 487 maxillary (396 size preserved), 131 mandibular (83 size preserved), and one paired dentition (two size preserved) matches were found. Principal component analysis and partial least squares revealed interpretable patterns of variation and covariation in dental shape, principally dominated by variation in dental arch width. The sensitivity of match rate to assumed degree of measurement error was also determined showing rapid increases in match rate as measurement error increased. In conclusion, the concept of dental uniqueness with regard to bitemark analysis should be approached with caution.

Multiple chronic conditions among adults aged 45 and over: trends over the past 10 years.

Studies suggest that the presence of multiple chronic conditions (MCC) adds a layer of complexity to disease management (1­6); recently the U.S. Department of Health and Human Services established a strategic framework for improving the health of this population (2). This report presents estimates of the population aged 45 and over with two or more of nine self-reported chronic conditions, using a definition of MCC that was consistent in the National Health Interview Survey (NHIS) over the recent 10-year period: hypertension, heart disease, diabetes, cancer, stroke, chronic bronchitis, emphysema, current asthma, and kidney disease. Examining trends in the prevalence of MCC informs policy on chronic disease management and prevention, and helps to predict future health care needs and use for Medicare and other payers.

Bitemarks: distortion and covariation of the maxillary and mandibular dentition as impressed in human skin.

In bitemark analysis the extent of distortion of both maxillary and mandibular arches and how one affects the other has not been studied. A single dentition was used to create 49 bites on unembalmed cadavers. Landmarks were placed on digital images of the bitemarks and scanned images of the biting dentition. A sample of 297 randomly acquired dental models was used for comparison purposes. Geometric morphometric techniques were utilized to statistically describe size and shape change, as well as the correlation between the two arches. Results indicate that the predominant distortion seen was in arch width, at 7-28 times as large as measurement error in the biting dentition and roughly 50% of the variation seen in the random population of dentitions. The correlation of arch width distortion between arches was very low (∼0.03). However, the principal patterns of all shape variation did co-vary in the bitemarks produced by the maxillary and mandibular dentition, an effect indicating independence of size and shape distortion. In conclusion, bitemark analysis should be approached with caution when the principal difference between suspects is arch width.

The crash of Colgan Air flight 3407: Advanced techniques in victim identification.

BACKGROUND: Identifying disaster victims by means of dental records is a well-established technique. In cases in which high temperatures are involved, destruction of the structural relationship of the dentition necessitates that adjunctive aids be used in the identification process. Analysis of tooth fragments by means of scanning electron microscopy with energy dispersive x-ray spectroscopy can reveal evidence of restorative procedures, as well as trace amounts of dental materials remaining on tooth surfaces. In addition, dental materials can be analyzed and identified according to brand, even if the materials have been cremated. CASE DESCRIPTION: The authors describe the identification of three victims from the crash of Colgan Air flight 3407, a commuter airplane flying between Newark, N.J., and Buffalo, N.Y. The crash involved a fire, and a portion of the airplane burned for nearly 11 hours. Dental fragments that had restorative material adhering to them were recovered and analyzed. These fragments contained corroborative information that helped confirm the identity of the victims. CLINICAL IMPLICATIONS: Detailed record keeping is part of clinical practice. The level of detail present in dental records can affect the ability of forensic odontologists to determine the identity of a victim's remains. Documenting the brand names of dental materials used in restorative procedures can make the difference between identifying and not identifying a victim's remains.

A study of multiple bitemarks inflicted in human skin by a single dentition using geometric morphometric analysis.

Criticisms of the forensic discipline of bitemark analysis state that the range of distortion in the shape of bitemark impressions in skin has not been scientifically established. No systematic statistical studies exist that explore this problem. As a preliminary investigation of this issue, a single dentition was mounted in a mechanical apparatus and used to create 89 bitemarks in human cadaver skin, both parallel and perpendicular to tension lines. Impressions of the same dentition were also created in wax. 2D scanned images of the biting dentition were obtained. Locations of incisal edges of all 6 anterior teeth as well as the midpoint of the canine were captured as landmarks in all specimens. This set of landmark data was then studied using established geometric morphometric methods. All specimen shapes were compared using Procrustes superimposition methods, and by a variation of Procrustes superimposition which preserves scale information. Match criteria were established by examining the range of variation produced by repeated measurements of the dentition for each class of specimen. The bitemarks were also compared to a population of 411 digitally scanned dentitions, again using the match criteria. Results showed that bitemarks in wax had lower measurement error than scanned images of the dentition, and both were substantially lower than measurement error as recorded in skin. None of the 89 bitemarks matched the measured shape of the biting dentition or bitemarks in wax, within the repeated measurements error level, despite the fact that all bitemarks were produced by this dentition. Comparison of the bitemarks to the collection of 411 dentitions showed that the closest match to the bitemarks was not always the same dentition that produced the bitemarks. Examination of Procrustes plots of matched shapes showed non-overlapping distributions of measurements of bitemarks in skin, wax, and the dentition. All had statistically significant differences in mean shape. Principal component analysis (PCA) and canonical variates analysis (CVA) both showed clear segregation of the three types of data. The patterns of variance revealed by PCA showed several distinct patterns produced by skin distortion; alteration of relative arch width, and varying displacement of non-aligned teeth in the dentition. These initial results indicate that when multiple suspects possess similar dentitions, bitemark analysis should be approached with caution.

Dental shape match rates in selected and orthodontically treated populations in New York State: a two-dimensional study.

Forensically identifying a suspect's dentition from a bitemark in an open population requires the supposition that every person's dental alignment is different. There have been few studies that have tested this claim. Four hundred and ten lower anterior dentitions from a selected population and 110 lower anterior dentitions from one that was orthodontically treated were measured using geometric morphometric analysis, allowing comparison of arch shape. Dental match rates of 1.46% and 42.7% of individuals were found in the respective populations, given an established measurement error. Orthodontic treatment had a strong effect on match rate suggesting that treated or naturally well-aligned dentitions may be indistinguishable. Sexual dimorphism was found to be only slightly significant. Principal shape variation in both populations was degree of arch curvature. Results of studying these populations show that dental matches can occur, and that statements of certainty concerning individualization in such populations should be approached with caution.

Mathematical matching of a dentition to bitemarks: use and evaluation of affine methods.

Skin is a less than ideal medium for recording bitemark impressions, and assessing the causes and magnitude of distortion has long been a question in forensic odontology. Affine methods have been suggested as a mathematical means to attempt to quantify the deformation typically seen with a bitemark. Thirty-six bites were created on unembalmed human cadavers with a single dentition. Three mathematical affine methods were evaluated to determine if the distortion could be described mathematically and effectively removed. A measure of mismatch of a dentition to a bitemark was developed based on landmark measurements establishing a numerical basis for comparisons of dentitions to bitemarks. Results indicate high levels of distortion in the bitemarks not attributable to affine deformations or measurement error, suggesting that non-uniform anisotropic properties of skin mostly contribute to the distortion seen, thus concluding that bitemark distortion cannot be corrected by using affine transformations.

Similarity and match rates of the human dentition in three dimensions: relevance to bitemark analysis.

Uniqueness of the human dentition is a fundamental premise in bitemark analysis. Despite the importance of this key aspect of bitemark methodology, systematic studies of large populations have been limited. Furthermore, there have been no investigations of the significance of the third dimension with regard to dental uniqueness. One hundred digitally scanned mandibular models were analyzed in both 2D and three dimension (3D) using Landmark software. Additionally, 500 3D maxillary and mandibular sets were investigated for determining dental match rate. Statistical analysis was performed with geometric morphometric methods. Results show that measurements in 3D preserve more information about the dentition, reducing but not eliminating random matches in a sample population of 100 mandibular dentitions. Examination of pairs of maxillary and mandibular dentitions showed a substantial number of random matches (197 maxillary, 51 mandibular, one of both maxillary and mandibular). Conclusions indicate that a zero match rate cannot be claimed for the population studied.

Statistical evidence for the similarity of the human dentition.

Recent scrutiny of forensic science has focused on unreliability of expert witness testimony when based on statements of individuality. In bitemark analysis, assumptions regarding uniqueness of the dentition have been based on use of the product rule while ignoring correlation and nonuniformity of dental arrangement. To examine the effect of these factors, two separate sets of scanned dental models (n=172 and n=344) were measured and statistically tested to determine match rates. Results were compared to those of a prior study. Seven and 16 matches of the six anterior lower teeth were found in the respective data sets. Correlations and nonuniform distributions of tooth positions were observed. Simulation tests were performed to verify results. Results indicate that given experimental measurement parameters, statements of dental uniqueness with respect to bitemark analysis in an open population are unsupportable and that use of the product rule is inappropriate.