Mammographic screening: Periodic imaging of both breasts using digital mammography ± digital breast tomosynthesis (DBT) in asymptomatic women to detect breast cancer
Earlier detection → ↓ node-positive invasive cancers → ↓ breast cancer mortality and morbidity
Mammography Quality Standards Act (MQSA) (USA)
Federal law (1992) with stringent quality standards for all stages and personnel involved
Governed by FDA &/or state with required regular QA process and annual inspections
Images interpreted by Mammography Quality Standards Act (MQSA)-certified breast imager (USA) or equivalent
Must be supported by accurate diagnostic assessment, expert image-guided needle biopsy, breast pathology, treatment
Online screening: Interpretation at time of examination with immediate provision of results
Offline screening: Mammograms batch-read, either later or remotely, by 1 or more radiologists
Postal (or phone call) recommendation to return for additional investigation
Results: Breast Imaging Reporting and Data System (BI-RADS) 1 (negative), 2 (benign), or 0 (incomplete, additional imaging needed, recall)
Recall rate = abnormal interpretation rate, i.e., percentage of women screened with recommendation for further testing prior to next routine mammogram
BI-RADS 0 (incomplete) recommended for additional evaluation
BI-RADS 3 assessment not to be used on screening mammography but would be considered recall
Includes BI-RADS 4 (suspicious) and BI-RADS 5 (highly suggestive of malignancy), but use of these is typically reserved for diagnostic setting
Excludes BI-RADS 1 or 2 assessment, even if therapeutic (but not diagnostic) cyst aspiration will be performed
Screening interval: Recommended time between screening exams
USA: American College of Radiology (ACR), National Comprehensive Cancer Network (NCCN): Every year beginning at age 40 and continuing as long as in good health
American Cancer Society (ACS): Offer at age 40-44; recommend at age 45; yearly for ages 40-54, biennial or annual for age ≥ 55; as long as life expectancy ≥ 10 years
National Cancer Institute (NCI): Every 1-2 years
US Preventive Services Task Force (USPSTF): Women aged 40-49 should discuss with their physicians; every 2 years from age 50-74
If high risk, screening recommended by age 25-30 (see guidelines for MR)
Canadian Task Force on Preventive Health Care: Every 2-3 years from age 50-74
European Society of Breast Imaging (EUSOBI): Every 2 years from age 50-69; extension to age 73-75 and from age 40-45 to 49 also encouraged
United Kingdom National Health Service: Every 3 years from age 50-70; in some parts of England, from age 47-73
Swedish program: Variable, every 18-24 months from age 40-50 to age 69 or 74
Austrian program: Every 18 months from age 45-54; every 2 years age 55-74 years
Dutch, Norwegian, Canadian, Australian, and New Zealand screening programs: Every 2 years from age 50-69
Japanese Breast Cancer Society: Start at age 40; do not specify interval or duration
True-positive: Tissue diagnosis of breast cancer within screening interval (typically 365 days in USA) after abnormal (positive) screening mammogram
Positive test: BI-RADS 0, 3, 4, 5 on screening (use of BI-RADS 3, 4, and 5 is discouraged for screening exams)
False-negative: Tissue diagnosis of breast cancer within screening interval after negative mammogram (BI-RADS 1 or 2 on screening or technical recall only)
Positive predictive value (PPV)
PPV1 = PPV of abnormal screening exams (# true-positive exams divided by # of all positive screening exams)
PPV2 = PPV of biopsies recommended (# true-positive exams divided by # of screening exams recommended for biopsy after full work-up)
PPV3 = PPV of biopsies performed (# true-positive exams divided by # of screening exams with biopsies actually performed after full work-up)
Cancer detection rate (CDR): # diagnosed with breast cancer per 1,000 screening examinations
Prevalent cancers are found on initial, baseline screening mammogram
Incident cancers are found on subsequent screening exam performed at or close to recommended screening interval
Interval cancers are diagnosed during time between recommended screening exams, typically due to clinical symptoms, after negative mammogram
Minimal cancer: Invasive cancer ≤ 1 cm or DCIS
Most audits performed at patient level (i.e., screening examination level), though can be performed at breast level
If patient recalled for finding other than area proven to be cancer within screening interval, this is still considered true-positive
Note: If patient diagnosed with cancer because of new screening examination performed prior to screening interval (e.g., 360 days after negative screen) and diagnosis of cancer made because of new finding on new mammogram, this is still considered false-negative for original negative screening mammogram even if cancer cannot be seen in retrospect
IMAGING
Imaging Anatomy
Anatomy-Based Imaging Issues
PATHOLOGY
Staging, Grading, & Classification
CLINICAL ISSUES
Demographics
Natural History & Prognosis
DIAGNOSTIC CHECKLIST
Consider
Reporting Tips
Selected References
Skaane P et al: Digital mammography versus digital mammography plus tomosynthesis in breast cancer screening: The Oslo Tomosynthesis Screening Trial. Radiology. 182394, 2019
Helvie MA et al: Screening mammography for average-risk women: the controversy and NCCN's position. J Natl Compr Canc Netw. 16(11):1398-1404, 2018
Klarenbach S et al: Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. CMAJ. 190(49):E1441-E1451, 2018
Lee CS et al: Harmonizing breast cancer screening recommendations: metrics and accountability. AJR Am J Roentgenol. 210(2):241-245, 2018
Mango V et al: Commentary ACOG practice bulletin July 2017: Breast cancer risk assessment and screening in average-risk women. Br J Radiol. 91(1090):20170907, 2018
Tabár L et al: The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 125(4):515-523, 2018
Lehman CD et al: National performance benchmarks for modern screening digital mammography: update from the Breast Cancer Surveillance Consortium. Radiology. 283(1):49-58, 2017
Monticciolo DL et al: Breast cancer screening for average-risk women: recommendations from the ACR commission on breast imaging. J Am Coll Radiol. 14(9):1137-1143, 2017
Sardanelli F et al: Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey. Eur Radiol. 27(7):2737-2743, 2017
Siu AL et al: Screening for breast cancer: U.S. Preventive Services Task force recommendation statement. Ann Intern Med. 164(4):279-96, 2016
Tozaki M et al: The Japanese Breast Cancer Society clinical practice guidelines for screening and imaging diagnosis of breast cancer, 2015 edition. Breast Cancer. 23(3):357-66, 2016
Oeffinger KC et al: Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 314(15):1599-614, 2015
Friedewald SM et al: Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 311(24):2499-507, 2014
Kerlikowske K et al: Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy. JAMA Intern Med. 173(9):807-16, 2013
Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
Hendrick RE et al: Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. AJR Am J Roentgenol. 198(3):723-8, 2012
Nishikawa RM et al: Clinically missed cancer: how effectively can radiologists use computer-aided detection? AJR Am J Roentgenol. 198(3):708-16, 2012
Hubbard RA et al: Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 155(8):481-92, 2011
Tabár L et al: Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 260(3):658-63, 2011
Carney PA et al: Identifying minimally acceptable interpretive performance criteria for screening mammography. Radiology. 255(2):354-61, 2010
Nelson HD et al: S. Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 151(10):727-37, W237-42, 2009
Hogben RK: Screening for breast cancer in England: a review. Curr Opin Obstet Gynecol. 20(6):545-9, 2008
Rosenberg RD et al: Performance benchmarks for screening mammography. Radiology. 241(1):55-66, 2006
Berry DA et al: Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 353(17):1784-92, 2005
Burnside ES et al: The use of batch reading to improve the performance of screening mammography. AJR Am J Roentgenol. 185(3):790-6, 2005
D'Orsi C et al: Current realities of delivering mammography services in the community: do challenges with staffing and scheduling exist? Radiology. 235(2):391-5, 2005
Hendrick RE et al: Community-based mammography practice: services, charges, and interpretation methods. AJR Am J Roentgenol. 184(2):433-8, 2005
Pisano ED et al: Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 353(17):1773-83, 2005
Smith RA et al: The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am. 42(5):793-806, v, 2004
Elmore JG et al: International variation in screening mammography interpretations in community-based programs. J Natl Cancer Inst. 95(18):1384-93, 2003
Tabar L et al: Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet. 361(9367):1405-10, 2003
Yen MF et al: Quantifying the potential problem of overdiagnosis of ductal carcinoma in situ in breast cancer screening. Eur J Cancer. 39(12):1746-54, 2003
Walter LC et al: Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 285(21):2750-6, 2001
Elmore JG et al: Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med. 338(16):1089-96, 1998
Wilson TE et al: Patient satisfaction with screening mammography: online vs off-line interpretation. Acad Radiol. 5(11):771-8, 1998
Hendrick RE et al: Benefit of screening mammography in women aged 40-49: a new meta-analysis of randomized controlled trials. J Natl Cancer Inst Monogr. (22):87-92, 1997
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KEY FACTS
Imaging
Clinical Issues
Diagnostic Checklist
TERMINOLOGY
Definitions
Mammographic screening: Periodic imaging of both breasts using digital mammography ± digital breast tomosynthesis (DBT) in asymptomatic women to detect breast cancer
Earlier detection → ↓ node-positive invasive cancers → ↓ breast cancer mortality and morbidity
Mammography Quality Standards Act (MQSA) (USA)
Federal law (1992) with stringent quality standards for all stages and personnel involved
Governed by FDA &/or state with required regular QA process and annual inspections
Images interpreted by Mammography Quality Standards Act (MQSA)-certified breast imager (USA) or equivalent
Must be supported by accurate diagnostic assessment, expert image-guided needle biopsy, breast pathology, treatment
Online screening: Interpretation at time of examination with immediate provision of results
Offline screening: Mammograms batch-read, either later or remotely, by 1 or more radiologists
Postal (or phone call) recommendation to return for additional investigation
Results: Breast Imaging Reporting and Data System (BI-RADS) 1 (negative), 2 (benign), or 0 (incomplete, additional imaging needed, recall)
Recall rate = abnormal interpretation rate, i.e., percentage of women screened with recommendation for further testing prior to next routine mammogram
BI-RADS 0 (incomplete) recommended for additional evaluation
BI-RADS 3 assessment not to be used on screening mammography but would be considered recall
Includes BI-RADS 4 (suspicious) and BI-RADS 5 (highly suggestive of malignancy), but use of these is typically reserved for diagnostic setting
Excludes BI-RADS 1 or 2 assessment, even if therapeutic (but not diagnostic) cyst aspiration will be performed
Screening interval: Recommended time between screening exams
USA: American College of Radiology (ACR), National Comprehensive Cancer Network (NCCN): Every year beginning at age 40 and continuing as long as in good health
American Cancer Society (ACS): Offer at age 40-44; recommend at age 45; yearly for ages 40-54, biennial or annual for age ≥ 55; as long as life expectancy ≥ 10 years
National Cancer Institute (NCI): Every 1-2 years
US Preventive Services Task Force (USPSTF): Women aged 40-49 should discuss with their physicians; every 2 years from age 50-74
If high risk, screening recommended by age 25-30 (see guidelines for MR)
Canadian Task Force on Preventive Health Care: Every 2-3 years from age 50-74
European Society of Breast Imaging (EUSOBI): Every 2 years from age 50-69; extension to age 73-75 and from age 40-45 to 49 also encouraged
United Kingdom National Health Service: Every 3 years from age 50-70; in some parts of England, from age 47-73
Swedish program: Variable, every 18-24 months from age 40-50 to age 69 or 74
Austrian program: Every 18 months from age 45-54; every 2 years age 55-74 years
Dutch, Norwegian, Canadian, Australian, and New Zealand screening programs: Every 2 years from age 50-69
Japanese Breast Cancer Society: Start at age 40; do not specify interval or duration
True-positive: Tissue diagnosis of breast cancer within screening interval (typically 365 days in USA) after abnormal (positive) screening mammogram
Positive test: BI-RADS 0, 3, 4, 5 on screening (use of BI-RADS 3, 4, and 5 is discouraged for screening exams)
False-negative: Tissue diagnosis of breast cancer within screening interval after negative mammogram (BI-RADS 1 or 2 on screening or technical recall only)
Positive predictive value (PPV)
PPV1 = PPV of abnormal screening exams (# true-positive exams divided by # of all positive screening exams)
PPV2 = PPV of biopsies recommended (# true-positive exams divided by # of screening exams recommended for biopsy after full work-up)
PPV3 = PPV of biopsies performed (# true-positive exams divided by # of screening exams with biopsies actually performed after full work-up)
Cancer detection rate (CDR): # diagnosed with breast cancer per 1,000 screening examinations
Prevalent cancers are found on initial, baseline screening mammogram
Incident cancers are found on subsequent screening exam performed at or close to recommended screening interval
Interval cancers are diagnosed during time between recommended screening exams, typically due to clinical symptoms, after negative mammogram
Minimal cancer: Invasive cancer ≤ 1 cm or DCIS
Most audits performed at patient level (i.e., screening examination level), though can be performed at breast level
If patient recalled for finding other than area proven to be cancer within screening interval, this is still considered true-positive
Note: If patient diagnosed with cancer because of new screening examination performed prior to screening interval (e.g., 360 days after negative screen) and diagnosis of cancer made because of new finding on new mammogram, this is still considered false-negative for original negative screening mammogram even if cancer cannot be seen in retrospect
IMAGING
Imaging Anatomy
Anatomy-Based Imaging Issues
PATHOLOGY
Staging, Grading, & Classification
CLINICAL ISSUES
Demographics
Natural History & Prognosis
DIAGNOSTIC CHECKLIST
Consider
Reporting Tips
Selected References
Skaane P et al: Digital mammography versus digital mammography plus tomosynthesis in breast cancer screening: The Oslo Tomosynthesis Screening Trial. Radiology. 182394, 2019
Helvie MA et al: Screening mammography for average-risk women: the controversy and NCCN's position. J Natl Compr Canc Netw. 16(11):1398-1404, 2018
Klarenbach S et al: Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. CMAJ. 190(49):E1441-E1451, 2018
Lee CS et al: Harmonizing breast cancer screening recommendations: metrics and accountability. AJR Am J Roentgenol. 210(2):241-245, 2018
Mango V et al: Commentary ACOG practice bulletin July 2017: Breast cancer risk assessment and screening in average-risk women. Br J Radiol. 91(1090):20170907, 2018
Tabár L et al: The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 125(4):515-523, 2018
Lehman CD et al: National performance benchmarks for modern screening digital mammography: update from the Breast Cancer Surveillance Consortium. Radiology. 283(1):49-58, 2017
Monticciolo DL et al: Breast cancer screening for average-risk women: recommendations from the ACR commission on breast imaging. J Am Coll Radiol. 14(9):1137-1143, 2017
Sardanelli F et al: Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey. Eur Radiol. 27(7):2737-2743, 2017
Siu AL et al: Screening for breast cancer: U.S. Preventive Services Task force recommendation statement. Ann Intern Med. 164(4):279-96, 2016
Tozaki M et al: The Japanese Breast Cancer Society clinical practice guidelines for screening and imaging diagnosis of breast cancer, 2015 edition. Breast Cancer. 23(3):357-66, 2016
Oeffinger KC et al: Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 314(15):1599-614, 2015
Friedewald SM et al: Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 311(24):2499-507, 2014
Kerlikowske K et al: Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy. JAMA Intern Med. 173(9):807-16, 2013
Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
Hendrick RE et al: Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. AJR Am J Roentgenol. 198(3):723-8, 2012
Nishikawa RM et al: Clinically missed cancer: how effectively can radiologists use computer-aided detection? AJR Am J Roentgenol. 198(3):708-16, 2012
Hubbard RA et al: Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 155(8):481-92, 2011
Tabár L et al: Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 260(3):658-63, 2011
Carney PA et al: Identifying minimally acceptable interpretive performance criteria for screening mammography. Radiology. 255(2):354-61, 2010
Nelson HD et al: S. Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 151(10):727-37, W237-42, 2009
Hogben RK: Screening for breast cancer in England: a review. Curr Opin Obstet Gynecol. 20(6):545-9, 2008
Rosenberg RD et al: Performance benchmarks for screening mammography. Radiology. 241(1):55-66, 2006
Berry DA et al: Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 353(17):1784-92, 2005
Burnside ES et al: The use of batch reading to improve the performance of screening mammography. AJR Am J Roentgenol. 185(3):790-6, 2005
D'Orsi C et al: Current realities of delivering mammography services in the community: do challenges with staffing and scheduling exist? Radiology. 235(2):391-5, 2005
Hendrick RE et al: Community-based mammography practice: services, charges, and interpretation methods. AJR Am J Roentgenol. 184(2):433-8, 2005
Pisano ED et al: Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 353(17):1773-83, 2005
Smith RA et al: The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am. 42(5):793-806, v, 2004
Elmore JG et al: International variation in screening mammography interpretations in community-based programs. J Natl Cancer Inst. 95(18):1384-93, 2003
Tabar L et al: Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet. 361(9367):1405-10, 2003
Yen MF et al: Quantifying the potential problem of overdiagnosis of ductal carcinoma in situ in breast cancer screening. Eur J Cancer. 39(12):1746-54, 2003
Walter LC et al: Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 285(21):2750-6, 2001
Elmore JG et al: Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med. 338(16):1089-96, 1998
Wilson TE et al: Patient satisfaction with screening mammography: online vs off-line interpretation. Acad Radiol. 5(11):771-8, 1998
Hendrick RE et al: Benefit of screening mammography in women aged 40-49: a new meta-analysis of randomized controlled trials. J Natl Cancer Inst Monogr. (22):87-92, 1997
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