Objectives. To study factors that predict changes in management with digital breast tomosynthesis (DBT). Methods. The Institutional Review Board approved this HIPAA compliant study. 996 patients had DBT with full field digital mammography (FFDM). Univariate analysis evaluated predictors of management change and cancer detection. Results. DBT changed management in 109 of 996 (11%); 77 (71%) required less imaging. Recalled patients after abnormal FFDM screen were most likely to have management change—25% (24 of 97 patients) compared to 8% (13/163) of symptomatic patients and 10% (72/736) of screening patients ( ). Dense breasted patients had a higher likelihood of having DBT change management: 13% (68/526) compared to 9% (41/470) ( ). Of the 996 patients, 19 (2%) were diagnosed with breast cancer. 15 cancers (83%) were seen on FFDM and DBT; 3 (17%) were diagnosed after DBT (0.3%, 95%CI: 0.1–0.9%). One recurrence was in the skin and was not seen on DBT nor was it seen on FFDM. The increase in cancer detection rate was 17% for asymptomatic patients, 0% for symptomatic patients, and 100% for recalled patients. Conclusions. DBT increased cancer detection rate by 20% and decreased the recall rate in 8–25%. Advances in Knowledge. DBT led to a doubling of the cancer detection rate in recalled patients. 1. Introduction Prospective trials of screening mammography demonstrate a reduction in breast cancer mortality [1, 2] yet concerns regarding false positive and false negative findings generate controversy [3]. In parallel with efforts to define populations who may benefit from supplemental ultrasound or MRI screening [4–8] technical innovations to improve mammography’s sensitivity and specificity have included full field digital mammography (FFDM) [9, 10], computer aided detection (CAD) [11], and digital breast tomosynthesis (DBT) [12]. DBT images potentially reduce false positives caused by overlapping tissues which can mimic cancer while simultaneously reducing false negatives caused by tissue overlap which could obscure malignancy. Thus, DBT improves the sensitivity of screening mammography compared with FFDM while decreasing recall rates [13–15]. Much work investigating DBT, however, has been retrospective or performed on enriched data sets [16–18] and there are few studies on the role of DBT in populations at elevated risk for breast cancer. In a meta-analysis of 14 studies, no data was available regarding the clinical variables associated with enhanced cancer detection by DBT [13]. Here, we investigated groups of patients for whom DBT altered management. We
References
[1]
R. A. Smith, S. W. Duffy, and L. Tabar, “Breast cancer screening: the evolving evidence,” Oncology, vol. 26, no. 5, pp. 471–486, 2012.
[2]
L. Tabár, B. Vitak, T. H.-H. Chen et al., “Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades,” Radiology, vol. 260, no. 3, pp. 658–663, 2011.
[3]
US Preventive Services Task Force, “Screening for breast cancer: US Preventive Services Task Force recommendation statement,” Annals of Internal Medicine, vol. 151, no. 10, pp. 716–726, 2009.
[4]
W. A. Berg, J. D. Blume, J. B. Cormack et al., “Combined screening with ultrasound and mammography vs. Mammography alone in women at elevated risk of breast cancer,” The Journal of the American Medical Association, vol. 299, no. 18, pp. 2151–2163, 2008.
[5]
W. A. Berg, Z. Zhang, D. Lehrer et al., “Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk,” The Journal of the American Medical Association, vol. 307, no. 13, pp. 1394–1404, 2012.
[6]
D. Saslow, C. Boetes, W. Burke et al., “American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography,” CA Cancer Journal for Clinicians, vol. 57, no. 2, pp. 75–89, 2007.
[7]
H.R. 3102–112th Congress: Breast Density and Mammography Reporting Act of 2011, http://www.govtrack.us/congress/bills/112/hr3102.
[8]
An Act to Add and Repeal Section 123222.3 of the Health and Safety Code, Relating to Mammograms, California State Senate, 11th Senate District, 2012.
[9]
E. D. Pisano, R. E. Hendrick, M. J. Yaffe et al., “Diagnostic accuracy of digital versus film mammography: exploratory analysis of selected population subgroups in DMIST,” Radiology, vol. 246, no. 2, pp. 376–383, 2008.
[10]
E. D. Pisano, C. Gatsonis, E. Hendrick et al., “Diagnostic performance of digital versus film mammography for breast-cancer screening,” The New England Journal of Medicine, vol. 353, no. 17, pp. 1773–1783, 2005.
[11]
R. F. Brem, J. Baum, M. Lechner et al., “Improvement in sensitivity of screening mammography with computer-aided detection: a multiinstitutional trial,” American Journal of Roentgenology, vol. 181, no. 3, pp. 687–693, 2003.
[12]
L. T. Niklason, B. T. Christian, L. E. Niklason et al., “Digital tomosynthesis in breast imaging,” Radiology, vol. 205, no. 2, pp. 399–406, 1997.
[13]
N. Houssami and P. Skaane, “Overview of the evidence on digital breast tomosynthesis in breast cancer detection,” The Breast, vol. 22, no. 2, pp. 101–108, 2013.
[14]
P. Skaane, R. Gullien, H. Bjorndal, et al., “Digital breast tomosynthesis (DBT): initial experience in a clinical setting,” Acta Radiologica, vol. 53, no. 5, pp. 524–529, 2012.
[15]
E. A. Rafferty, J. M. Park, L. E. Philpotts, et al., “Assessing radiologist performance using combined digital mammography and breast tomosynthesis compared with digital mammography alone: results of a multicenter, multireader trial,” Radiology, vol. 266, no. 1, pp. 104–113, 2013.
[16]
M. G. Wallis, E. Moa, F. Zanca, K. Leifland, and M. Danielsson, “Two-view and single-view tomosynthesis versus full-field digital mammography: high-resolution X-ray imaging observer study,” Radiology, vol. 262, no. 3, pp. 788–796, 2012.
[17]
M. Noroozian, L. Hadjiiski, S. Rahnama-Moghadam et al., “Digital breast tomosynthesis is comparable to mammographic spot views for mass characterization,” Radiology, vol. 262, no. 1, pp. 61–68, 2012.
[18]
D. Gur, M. L. Zuley, M. I. Anello et al., “Dose reduction in digital breast tomosynthesis (DBT) screening using synthetically reconstructed projection images: an observer performance study,” Academic Radiology, vol. 19, no. 2, pp. 166–171, 2012.
[19]
C. J. D'Orsi, L. W. Bassett, W. A. Berg, et al., “BI-RADS: mammography,” in Breast Imaging Reporting and Data System: ACR BI-RADS—Breast Imaging Atlas, C. J. D'Orsi, E. B. Mendelson, and D. M. Ikeda, Eds., American College of Radiology, Reston, Va, USA, 4th edition, 2003.
[20]
P. Skaane, A. I. Bandos, R. Gullien, et al., “Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program,” Radiology, vol. 267, no. 1, pp. 47–56, 2013.
[21]
B. M. Haas, V. Kalra, J. Geisel, M. Raghu, M. Durand, and L. E. Philpotts, “Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening,” Radiology, vol. 269, no. 3, pp. 694–700, 2013.
[22]
A. Tagliafico, D. Astengo, F. Cavagnetto et al., “One-to-one comparison between digital spot compression view and digital breast tomosynthesis,” European Radiology, vol. 22, no. 3, pp. 539–544, 2012.
[23]
S. P. Poplack, T. D. Tosteson, C. A. Kogel, and H. M. Nagy, “Digital breast tomosynthesis: initial experience in 98 women with abnormal digital screening mammography,” American Journal of Roentgenology, vol. 189, no. 3, pp. 616–623, 2007.
[24]
R. M. Tamimi, C. Byrne, G. A. Colditz, and S. E. Hankinson, “Endogenous hormone levels, mammographic density, and subsequent risk of breast cancer in postmenopausal women,” Journal of the National Cancer Institute, vol. 99, no. 15, pp. 1178–1187, 2007.
[25]
N. F. Boyd, L. J. Martin, J. M. Rommens et al., “Mammographic density: a heritable risk factor for breast cancer,” Methods in Molecular Biology, vol. 472, pp. 343–360, 2009.
[26]
M. T. Mandelson, N. Oestreicher, P. L. Porter et al., “Breast density as a predictor of mammographic detection: comparison of interval-and screen-detected cancers,” Journal of the National Cancer Institute, vol. 92, no. 13, pp. 1081–1087, 2000.
[27]
K. Kerlikowske, D. Grady, J. Barclay, E. A. Sickles, and V. Ernster, “Effect of age, breast density, and family history on the sensitivity of first screening mammography,” The Journal of the American Medical Association, vol. 276, no. 1, pp. 33–38, 1996.
[28]
N. F. Boyd, H. Guo, L. J. Martin et al., “Mammographic density and the risk and detection of breast cancer,” The New England Journal of Medicine, vol. 356, no. 3, pp. 227–236, 2007.
[29]
D. B. Kopans, “Digital breast tomosynthesis: a better mammogram,” Radiology, vol. 267, no. 3, pp. 968–969, 2013.
[30]
C. Waldherr, P. Cerny, H. J. Altermatt, et al., “Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening,” American Journal of Roentgenology, vol. 200, no. 1, pp. 226–231, 2013.
[31]
M. J. Michell, A. Iqbal, R. K. Wasan, et al., “A comparison of the accuracy of film-screen mammography, full-field digital mammography, and digital breast tomosynthesis,” Clinical Radiology, vol. 67, no. 10, pp. 976–981, 2012.
[32]
C. M. Hakim, D. M. Chough, M. A. Ganott, J. H. Sumkin, M. L. Zuley, and D. Gur, “Digital breast tomosynthesis in the diagnostic environment: a subjective side-by-side review,” American Journal of Roentgenology, vol. 195, no. 2, pp. W172–W176, 2010.
[33]
K. R. Brandt, D. A. Craig, T. L. Hoskins, et al., “Can digital breast tomosynthesis replace conventional diagnostic mammography views for screening recalls without calcifications? A comparison study in a simulated clinical setting,” American Journal of Roentgenology, vol. 200, no. 2, pp. 291–298, 2013.
[34]
R. J. Hooley, K. L. Greenberg, R. M. Stackhouse, J. L. Geisel, R. S. Butler, and L. E. Philpotts, “Screening US in patients with mammographically dense breasts: initial experience with Connecticut public act 09-41,” Radiology, vol. 265, no. 1, pp. 59–69, 2012.
[35]
F. M. Hall, R. J. Hooley, K. Greenberg, et al., “Breast density legislation,” Radiology, vol. 266, no. 3, pp. 997–998, 2013.
[36]
I. J. Hall, A. Middlebrooks, and S. S. Coughlin, “Population prevalence of first-degree family history of breast and ovarian cancer in the United States: implications for genetic testing,” The Open Health Services and Policy Journal, vol. 1, pp. 34–37, 2008.
