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.

Does Direct Radiologist-Patient Verbal Communication Affect Follow-Up Compliance of Probably Benign Assessments?

PURPOSE: The aim of this study was to determine whether direct verbal communication of results by a radiologist affected follow-up compliance rates for probably benign breast imaging findings. METHODS: This study was institutional review board approved and HIPAA compliant. A retrospective search identified all patients from January 1, 2010 to December 31, 2010 who had breast findings newly assessed as probably benign (BI-RADS category 3). Patients were categorized by whether the radiologist or the technologist verbally communicated the result and follow-up recommendation. Patient adherence to 6-, 12-, and 24-month follow-up imaging recommendations was recorded. RESULTS: Compliance data were available for 770 of 819 patients in the study. Overall compliance was 83.0% (639 of 770) for 6-month examinations, 68.1% (524 of 770) for 6- and 12-month examinations, and 57.4% (442 of 770) for 6-, 12-, and 24-month examinations. For patients who initially underwent diagnostic mammography alone, there was no significant difference in compliance between those who had and those who did not have radiologist-patient communication (6 months, 81.9% vs 80.8% [P = .83]; 6 and 12 months, 70.8% vs 67.3% [P = .58]; 6, 12, and 24 months, 54.2% vs 58.4% [P = .53]). For patients who initially underwent diagnostic mammography alone versus ultrasound with or without diagnostic mammography, there was no significant difference in compliance (6 months, 81.1% vs 84.3% [P = .24]; 6 and 12 months, 68.1% vs 68.0% [P = .96]; 6, 12, and 24 months, 57.4% vs 57.4% [P = .00]). CONCLUSIONS: High initial compliance was achieved by radiologist or technologist verbal communication of findings and recommendations. Direct communication by the radiologist did not increase compliance compared with communication by a technologist.

Breast imaging after dark: patient outcomes following evaluation for breast abscess in the emergency department after hours.

In our study, we sought to report the management, clinical outcomes, and follow-up rates of patients who presented for evaluation of breast abscess in the Emergency Department (ED) after hours. A retrospective search of ultrasound reports at our institution identified all patients from January 1, 2009 to June 30, 2013 who were scanned in the ED after hours to evaluate for breast abscess. Patient demographics, clinical information, imaging findings, follow-up rates, and outcomes were reviewed. One hundred eighty-five patients were included in the study. Forty-four percent (86/185) of the patients were diagnosed with abscess based on ultrasound findings in the ED. Twenty-seven percent (23/86) were recently post-operative, and 12 % (10/86) were postpartum/breastfeeding. Mastitis was the diagnosis in the remaining 54 % (99/185). Only 1/86 cases were associated with breast cancer. Seventy-seven percent (66/86) of patients were treated with an invasive procedure; 39 % (26/66) had surgical evacuation, 30 % (20/66) image-guided drainage, 23 % (15/66) bedside or clinic incision and drainage, and 8 % (5/66) palpation-guided fine needle aspiration (FNA). Seventy-seven percent (143/185) of patients had clinical and/or imaging follow-up. Forty-four percent (63/143) had long-term follow-up (≥ 3 months). Almost 50 % of the patients who presented to the ED for evaluation of abscess were diagnosed with abscess while the remaining patients were diagnosed with mastitis. Appropriate clinical and/or imaging follow-up occurred in 77 %. Long-term follow-up (≥ 3 months) occurred more frequently in patients older than 30 years of age. Appropriate follow-up does not occur in approximately one fourth of cases, suggesting that additional clinician and patient education is warranted.

Update on new technologies in digital mammography.

Despite controversy regarding mammography's efficacy, it continues to be the most commonly used breast cancer-screening modality. With the development of digital mammography, some improved benefit has been shown in women with dense breast tissue. However, the density of breast tissue continues to limit the sensitivity of conventional mammography. We discuss the development of some derivative digital technologies, primarily digital breast tomosynthesis, and their strengths, weaknesses, and potential patient impact.

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.

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.

Update on emerging technologies in breast imaging.

Despite mammography's proven efficacy, there continues to be interest in newer technologies in breast cancer detection and expanded use of established technologies, especially in women with dense breast tissue and those at high risk. This article reflects on the development in the last ten years of some of these modalities and their current use.

Triple receptor-negative breast cancer: imaging and clinical characteristics.

OBJECTIVE: The objective of our study was to retrospectively evaluate the imaging findings of patients with breast cancer negative for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2)-so-called "triple receptor-negative cancer"-and to compare the mammographic findings and clinical characteristics of triple receptor-negative cancer with non-triple receptor-negative cancers (i.e., ER-positive, PR-positive, or HER2-positive or two of the three markers positive). CONCLUSION: Triple receptor-negative cancer was most commonly an irregular noncalcified mass with ill-defined or spiculated margins on mammography and a hypoechoic or complex mass with an irregular shape and noncircumscribed margins on ultrasound. Most triple receptor-negative cancers were discovered on physical examination. Compared with non-triple receptor-negative cancers, triple receptor-negative cancers were found in younger women and were a higher pathologic grade.

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.

Multi-modality CADx: ROC study of the effect on radiologists' accuracy in characterizing breast masses on mammograms and 3D ultrasound images.

RATIONALE AND OBJECTIVES: To investigate the effect of a computer-aided diagnosis (CADx) system on radiologists' performance in discriminating malignant and benign masses on mammograms and three-dimensional (3D) ultrasound (US) images. MATERIALS AND METHODS: Our dataset contained mammograms and 3D US volumes from 67 women (median age, 51; range: 27-86) with 67 biopsy-proven breast masses (32 benign and 35 malignant). A CADx system was designed to automatically delineate the mass boundaries on mammograms and the US volumes, extract features, and merge the extracted features into a multi-modality malignancy score. Ten experienced readers (subspecialty academic breast imaging radiologists) first viewed the mammograms alone, and provided likelihood of malignancy (LM) ratings and Breast Imaging and Reporting System assessments. Subsequently, the reader viewed the US images with the mammograms, and provided LM and action category ratings. Finally, the CADx score was shown and the reader had the opportunity to revise the ratings. The LM ratings were analyzed using receiver-operating characteristic (ROC) methodology, and the action category ratings were used to determine the sensitivity and specificity of cancer diagnosis. RESULTS: Without CADx, readers' average area under the ROC curve, A(z), was 0.93 (range, 0.86-0.96) for combined assessment of the mass on both the US volume and mammograms. With CADx, their average A(z) increased to 0.95 (range, 0.91-0.98), which was borderline significant (P = .05). The average sensitivity of the readers increased from 98% to 99% with CADx, while the average specificity increased from 27% to 29%. The change in sensitivity with CADx did not achieve statistical significance for the individual radiologists, and the change in specificity was statistically significant for one of the radiologists. CONCLUSIONS: A well-trained CADx system that combines features extracted from mammograms and US images may have the potential to improve radiologists' performance in distinguishing malignant from benign breast masses and making decisions about biopsies.

Women's mammography experience and its impact on screening adherence.

OBJECTIVES: Although rates for first-time and recent mammography screening have increased for women in the US in the past decade, rates for repeat mammography remain low. This study aimed to conduct an analysis of women's mammography experience, to examine the rates of repeat mammography and to identify the significant predictors of repeat mammography within 12 and 18 months of the index mammogram. METHODS: Participants were 397 women obtaining a screening mammogram (i.e. index) at three university-affiliated radiology clinics. Following the index mammogram, women completed the measures assessing demographic background, health history, breast cancer knowledge, risk, and screening history, and aspects of the mammography experience. Eighteen months following the index mammogram, 296 women were contacted via telephone to assess repeat mammography behavior. RESULTS: Factor analysis of a mammography experience survey yielded four major components including satisfaction with clinic services, physical experience, psychological experience, and communication with clinic staff. Twelve-month and 18-month repeat mammography rates were 37 and 68%, respectively. Logistic regression models found lifetime number of mammograms to predict repeat mammography at 12 and 18 months. In addition, the number of clinical breast exams obtained in the past 5 years predicted repeat mammography at 12 months, while having scheduled a mammography appointment predicted repeat mammography at 18 months. CONCLUSIONS: Based on these findings, strategies to increase mammography adherence include implementing a formal reminder system that prompts patients (e.g. postcard, automated telephone call) to schedule an annual mammogram or training clinic staff to automatically schedule an annual mammogram at the time of the current screening appointment.

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.

Outcome of men presenting with clinical breast problems: the role of mammography and ultrasound.

The purpose of this study was to determine the outcome of men presenting with clinical breast problems for breast imaging and to evaluate the role of mammography and ultrasound in the diagnosis of benign and malignant breast problems. We retrospectively reviewed clinical, radiographic, and pathologic records of 165 consecutive symptomatic men presenting to Breast Imaging over a 4 year period. We assessed the clinical indication for referral, mammographic findings, sonographic findings, histologic results, and clinical outcomes. Patients ranged in age from 22 to 96 years. Breast Imaging Reporting and Data System (BI-RADS) category 4 and 5 mammograms and solid sonographic masses were considered suspicious for malignancy. Six of 165 men (4%) had primary breast carcinoma, which were mammographically suspicious in all 6 (100%). Five were invasive ductal carcinoma and one was ductal carcinoma in situ (DCIS). Of 164 mammograms, 20 (12%) were suspicious. Six were cancer and 14 were benign. Clinical follow-up for 2 years or biopsy results were available for 138 of the 165 men (84%). Twelve with benign mammographic findings had benign biopsies. All men with benign mammography not undergoing biopsy were cancer free. Sensitivity for cancer detection (mammography) was 100% and specificity was 90%. Positive predictive value (mammography) was 32% (6 of 19) and the negative predictive value was 100%. Sonography was performed in 68 of the 165 men (41%). Three of three cancers (100%) were solid sonographic masses. There were 9 of 68 false-positive examinations (13%). Sensitivity and negative predictive value for cancer detection (ultrasound) was 100% and specificity was 74%. The most common clinical indication for referral was mass/thickening (56%). Mammography had excellent sensitivity and specificity for breast cancer detection and should be included as the initial imaging examination of men with clinical breast problems. The negative predictive value of 100% for mammography suggests that mammograms read as normal or negative need no further examination if the clinical findings are not suspicious. A normal ultrasound in these men confirms the negative predictive value of a normal mammogram.

Breast masses: computer-aided diagnosis with serial mammograms.

PURPOSE: To retrospectively evaluate effects of computer-aided diagnosis (CAD) involving an interval change classifier (which uses interval change information extracted from prior and current mammograms and estimates a malignancy rating) on radiologists' accuracy in characterizing masses on two-view serial mammograms as malignant or benign. MATERIALS AND METHODS: The data collection protocol had institutional review board approval. Patient informed consent was waived for this HIPAA-compliant retrospective study. Ninety temporal pairs of two-view serial mammograms (depicting 47 malignant and 43 benign biopsy-proved masses) were obtained from 68 patient files and were digitized. Biopsy was the reference standard. Eight Mammography Quality Standards Act of 1992-accredited radiologists and two breast imaging fellows assessed digitized two-view temporal pairs (in preselected regions of interest only) by estimating likelihood of malignancy and Breast Imaging Reporting and Data System (BI-RADS) category without and with CAD. Observers' rating data were analyzed with Dorfman-Berbaum-Metz (DBM) multireader multicase method. Statistical significance of differences was estimated with the DBM method and Student two-tailed paired t test. RESULTS: Average area under the receiver operating characteristic curve for likelihood of malignancy across the 10 observers was 0.83 (range, 0.74-0.88) without CAD and improved to 0.87 (range, 0.80-0.92) with CAD (P < .05). The average partial area index above a sensitivity of 0.90 for likelihood of malignancy was 0.35 (range, 0.13-0.54) without CAD and 0.49 (range, 0.18-0.73) with CAD--a nonsignificant improvement (P = .11). For BI-RADS assessment, it was estimated that with CAD, six radiologists would correctly recommend additional biopsies for malignant masses (range, 4.3%-10.6%) and five would correctly recommend reduction of biopsy (ie, fewer biopsies) for benign masses (range, 2.3%-9.3%). However, five radiologists would incorrectly recommend additional biopsy for benign masses (range, 2.3%-14.0%), and one would incorrectly recommend reduction of biopsy (4.3%). CONCLUSION: CAD involving interval change analysis of preselected regions of interest can significantly improve radiologists' accuracy in classifying masses on digitized screen-film mammograms as malignant or benign.

Colorectal cancer screening behavior in women attending screening mammography: longitudinal trends and predictors.

PURPOSE: Nationally representative surveys demonstrate that the adherence to screening mammography guidelines are associated with increased prevalence of colorectal cancer (CRC) screening; however, the incidence of CRC screening in the screening mammography population is unknown. Our purpose was to describe non-fecal occult blood test (FOBT) CRC screening utilization by women prior to and subsequent to screening mammography at a large academic medical center. MATERIALS AND METHODS: Using the institutional administrative data base, 17,790 women aged 50 and older who underwent screening mammography between 1998 and 2002 were retrospectively identified. We determined that women were current with non-FOBT CRC screening at the time of mammography if they had undergone flexible sigmoidoscopy or double-contrast barium enema in the 5 years or colonoscopy since 1995, the earliest for which data are available. We excluded FOBT as a form of CRC screening because the administrative data base did not adequately capture episodes of FOBT. Women who were not current were considered eligible for non-FOBT CRC screening. We then assessed the number of women who underwent flexible sigmoidoscopy, barium enema, or colonoscopy within 12 months following mammography. Age, insurance status, Breast Imaging Reporting and Data System classification, recommendations after screening mammography and year of mammography were examined as potential predictors of non-FOBT CRC screening completion. RESULTS: At the time of mammography, 13.3% women were current with non-FOBT CRC screening. Of women eligible for non-FOBT CRC screening at the time of mammography, 1.1% completed non-FOBT CRC screening within 12 months after mammography. The rate of non-FOBT CRC screening completion increased over time. After multivariate analysis, being insured by a commercial managed care organization or by Medicaid remained significant predictors of non-FOBT CRC screening. CONCLUSION: The prevalence of non-FOBT CRC screening is low in the population of women undergoing screening mammography, with an incidence of 1.0%. Future studies should examine whether delivering CRC screening interventions at a screening mammography visit increase adherence to non-FOBT CRC screening.

Associations in breast and colon cancer screening behavior in women.

RATIONALE AND OBJECTIVES: Gender-based psychosocial factors appear to influence colorectal cancer (CRC) screening adherence. Given its near-universal acceptance by the public, screening mammography represents a potential "teachable moment" for educating patients about the risk of CRC. Accordingly, to better understand screening behaviors among women, data from the Behavioral Risk Factors Surveillance Survey (BRFSS) were analyzed to identify potential relationships that would allow interventions to enhance CRC screening. MATERIALS AND METHODS: Women 50 years and older who participated in the BRFSS 2001 survey were included in the analysis. Colorectal, breast, and cervical cancer screening adherence with American Cancer Society guidelines was determined. We identified the association between breast and cervical cancer screening adherence and general health and demographic characteristics with CRC screening adherence. RESULTS: After adjustment for sociodemographic factors in a multivariate analysis, women 60-69 years old (adjusted odds ratio [OR], 1.50; P < .01) and 70-79 years old (adjusted OR, 1.39; P < .01), having achieved at least some high school (adjusted OR, 1.62; P < .01) or college (adjusted OR, 2.11; P < .01) education, having health coverage (adjusted OR, 1.67; P < .01) or a personal physician (adjusted OR, 1.60; P < .01), and adherence to screening mammography (adjusted OR, 2.42; P < .01) and Pap smear (adjusted OR, 1.70; P < .01) were independently associated with an increased likelihood CRC screening adherence. Women in self-reported good general health were less likely to have adhered to CRC screening guidelines (adjusted OR, 0.79; P < .01). Current smokers were also less likely to have adhered to CRC screening guidelines than were women who never smoked or formerly smoked (adjusted OR, 0.76; P < .01). Participants who adhered to both mammography and Pap smear guidelines were significantly more likely to adhere to CRC screening (51.5% CRC screening adherence) compared with women who adhered to neither screening test (8.2% CRC screening adherence), with an adjusted OR of 5.67 (P < .001). Participants who adhered to both mammography and Pap smear guidelines were significantly more likely to adhere to CRC screening than were women who adhered to either screening test (38.0% CRC screening adherence) with an adjusted OR of 1.94 (P < .001). CONCLUSION: Women with up-to-date mammography and cervical cancer screening were more likely to be up-to-date with CRC screening. Regardless of the increased association between non-CRC-related cancer screening and CRC screening, rates of CRC screening utilization remained low in these otherwise compliant populations.