Comparison of the Performance of Screening Mammography, Physical Examination, and Breast US and Evaluation of Factors that Influence Them: An Analysis of 27,825 Patient Evaluations

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Abstract

To (a) determine the performance of screening mammography, ultrasonography (US), and physical examination (PE); (b) analyze the influence of age, hormonal status, and breast density; (c) compare the size and stage of tumors detected with each modality; and (d) determine which modality or combination of modalities optimize cancer detection. A total of 11,130 asymptomatic women underwent 27,825 screening sessions, (mammography and subsequent PE). Women with dense breasts subsequently underwent screening US. Abnormalities were deemed positive if biopsy findings revealed malignancy and negative if findings from biopsy or all screening examinations were negative. In 221 women, 246 cancers were found. Sensitivity, specificity, negative and positive predictive values, and accuracy of mammography were 77.6%, 98.8%, 99.8%, 35.8%, and 98.6%, respectively; those of PE, 27.6%, 99.4%, 99.4%, 28.9%, and 98.8%, respectively; and those of US, 75.3%, 96.8%, 99.7%, 20.5%, and 96.6%, respectively. Screening breast US increased the number of women diagnosed with nonpalpable invasive cancers by 42% (30 of 71). Mammographic sensitivity declined significantly with increasing breast density (P <.01) (48% for the densest breasts) and in younger women with dense breasts (P =.02); the effects were independent. Mammography and US together had significantly higher sensitivity (97%) than did mammography and PE together (74%) (P <.001). Tumors detected at mammography and/or US were significantly smaller (P =.01) and of lower stage (P =.01) than those detected at PE. Mammographic sensitivity for breast cancer declines significantly with increasing breast density and is independently higher in older women with dense breasts. Addition of screening US significantly increases detection of small cancers and depicts significantly more cancers and at smaller size and lower stage than does PE, which detects independently extremely few cancers. Hormonal status has no significant effect on effectiveness of screening independent of breast density.

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Breast density as a predictor of mammographic detection: comparison of interval- and screen-detected cancers.

M T Mandelson, N Oestreicher, P. Porter … (2000)

Screening mammography is the best method to reduce mortality from breast cancer, yet some breast cancers cannot be detected by mammography. Cancers diagnosed after a negative mammogram are known as interval cancers. This study investigated whether mammographic breast density is related to the risk of interval cancer. Subjects were selected from women participating in mammographic screening from 1988 through 1993 in a large health maintenance organization based in Seattle, WA. Women were eligible for the study if they had been diagnosed with a first primary invasive breast cancer within 24 months of a screening mammogram and before a subsequent one. Interval cancer case subjects (n = 149) were women whose breast cancer occurred after a negative or benign mammographic assessment. Screen-detected control subjects (n = 388) were diagnosed after a positive screening mammogram. One radiologist, who was blinded to cancer status, assessed breast density by use of the American College of Radiology Breast Imaging Reporting and Data System. Mammographic sensitivity (i.e., the ability of mammography to detect a cancer) was 80% among women with predominantly fatty breasts but just 30% in women with extremely dense breasts. The odds ratio (OR) for interval cancer among women with extremely dense breasts was 6.14 (95% confidence interval [CI] = 1.95-19.4), compared with women with extremely fatty breasts, after adjustment for age at index mammogram, menopausal status, use of hormone replacement therapy, and body mass index. When only those interval cancer cases confirmed by retrospective review of index mammograms were considered, the OR increased to 9.47 (95% CI = 2.78-32.3). Mammographic breast density appears to be a major risk factor for interval cancer.

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Mammographic screening and mortality from breast cancer: the Malmö mammographic screening trial.

K Aspegren, Dan Andersson, L. Janzon … (1988)

To determine whether mortality from breast cancer could be reduced by repeated mammographic screening. Birth year cohorts of city population separately randomised into study and control groups. Screening clinic outside main hospital. Women aged over 45; 21,088 invited for screening and 21,195 in control group. Women in the study group were invited to attend for mammographic screening at intervals of 18-24 months. Five rounds of screening were completed. Breast cancer was treated according to stage at diagnosis. Mortality from breast cancer. All women were followed up and classed at end point as alive without breast cancer, alive with breast cancer, dead from breast cancer, or dead from other causes. Cause of death was taken from national mortality registry and for patients with breast cancer was validated independently. Mean follow up was 8.8 years. Altogether 588 cases of breast cancer were diagnosed in the study group and 447 in the control group; 99 v 94 women died of all causes and 63 v 66 women died of breast cancer (no significant difference; relative risk 0.96 (95% confidence interval 0.68 to 1.35)). In the study group 29% more women aged less than 55 died of breast cancer (28 v 22; relative risk 1.29 (0.74 to 2.25)). More women in the study group died from breast cancer in the first seven years; after that the trend reversed, especially in women aged greater than or equal to 55 at entry. Overall, women in the study group aged greater than or equal to 55 had a 20% reduction in mortality from breast cancer (35 v 44; relative risk 0.79 (0.51 to 1.24)). OTHER FINDINGS: In the study group 100 (17%) cancers appeared in intervals between screenings and 107 (18%) in non-attenders; 51 of these women died from breast cancer. Cancers classed as stages II-IV comprised 33% (190/579) of cancers in the study group and 52% (231/443) in the control group. Invitation to mammographic screening may lead to reduced mortality from breast cancer, at least in women aged 55 or over.