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BCSC Newsletter for October 2015

Table of Contents

BCSC in the News

Immediate Impact of BCSC study on Ineffectiveness of CAD

Science tends to make a steady march towards progress, but once in a while a study has a sudden and powerful influence over policy. A new BCSC study published September 28, 2015 in JAMA Internal Medicine has done just that by providing the best evidence to date that Computer-aided detection (CAD) doesn't improve the accuracy of digital screening mammography, and that insurers are paying for it - with no likely benefit.

In 1998 the FDA approved CAD for mammography. Today, CAD is used for most screening mammograms in the United States and costs approximately $400 million a year - even though there is little evidence that it improves accuracy. There have been immediate discussions about re-evaluating coverage for CAD since the publication:

The study garnered media attention from outlets such as Bloomberg NewsExternal Web Site Policy, HealthDayExternal Web Site Policy, Associated PressExternal Web Site Policy, ReutersExternal Web Site Policy, Time.com External Web Site Policy, MedscapeExternal Web Site Policy, Aunt MinnieExternal Web Site Policy and the Seattle TimesExternal Web Site Policy, and comes on the heels of another BCSC study, published in 2011, which also raised concerns about the effectiveness of CAD.

Widespread Media Attention for BCSC Study on Breast Density and Breast Cancer Risk

Women with dense breasts are at higher risk for breast cancer and mammography does not work as well in these women, but a new BCSC studyExternal Web Site Policy published May 18, 2015 in the Annals of Internal Medicine suggests that breast density should be just one part of the equation in determining who is at high risk of having a cancer missed on digital mammography. The study was picked as “Leading the News” for RSNA weeklyExternal Web Site Policy and received widespread media attention, with over 50 media references. The results provide more evidence that breast density alone may not be enough to justify supplemental screening and that overall breast cancer risk needs to be considered.

Below is a sample of the many media outlets which carried this story: The New York TimesExternal Web Site Policy, NPRExternal Web Site Policy, Time MagazineExternal Web Site Policy , ReutersExternal Web Site Policy, National Cancer Institute Blog, MedscapeExternal Web Site Policy, Daily RX TodayExternal Web Site Policy, Business InsiderExternal Web Site Policy, MedPage TodayExternal Web Site Policy, Tech TimesExternal Web Site Policy, and Self MagazineExternal Web Site Policy.

BCSC Risk Calculator Updated to include Benign Breast Disease

In 2013 The Breast Cancer Surveillance Consortium (BCSC) developed a web-based BCSC Risk Calculator for health professionals to estimate a woman's five-year risk of developing invasive breast cancer and now the BCSC risk model has been updated to include benign breast disease.External Web Site Policy The updated model was published in the Journal of Clinical Oncology on Aug 17, 2015 and led by Dr. Jeff Tice.

In 2015 free iPhone and iPad appsExternal Web Site Policy were created and both have been recently updated in addition to the web-based application. Since then the iPhone app has been downloaded over 1,330 times. In addition to public use, the calculator has been scientifically validatedExternal Web Site Policy and used as part of a research analysis. It has also been featured in the following news outlets:

Breast biopsies may not be reliable in identifying subtle abnormalities

The New York Times featuredExternal Web Site Policy an interesting, if somewhat worrisome, studyExternal Web Site Policy by Joann Elmore MDExternal Web Site Policy which was published March 17, 2015 in the Journal of American Medical Association (JAMA). The study found that biopsy results, which have long been considered the diagnosis gold standard, may be less reliable when the findings are for DCIS and atypia. On the bright side, there was high concordance (96%) when diagnosing invasive cancer. Two BCSC breast-imaging registries, The New Hampshire Mammography RegistryExternal Web Site Policy and the Vermont Breast Cancer Surveillance SystemExternal Web Site Policy contributed data to this important research.

Few Advanced Imaging Services available at nonacademic and non-radiology practices

A BCSC study, by Christoph Lee, MDExternal Web Site Policy, found that women who obtained mammography screening at multispecialty breast centers or full diagnostic radiology practices were more likely to have advanced breast imaging services at the same location, compared with women who went to non-radiology or breast imaging-only practices. The study was featured in Health Imaging MagazineExternal Web Site Policy. Health Imaging is a leading news website that reflects the clinical, informatics and practice management considerations involved with medical imaging.

Aunt Minnie covers four BCSC Publications

Four publications were highlighted by AuntMinnie.comExternal Web Site Policy, which provides a “comprehensive community Internet site for radiologists and related professionals in the medical imaging industry.” One BCSC study, led by BCSC researcher Louise Henderson, PhDExternal Web Site Policy, found that technologists can affect the accuracy of mammogram interpretations and that there were “significant fluctuations in recall rate, cancer detection rate, sensitivity, and specificity for screening mammography, depending on the radiologic technologist who performed the imaging.”

A second studyExternal Web Site Policy, led by BCSC researcher Diana Miglioretti, PhDExternal Web Site Policy, proposed criteria for identifying physicians whose performance interpreting screening mammography may indicate suboptimal interpretation skills. Prior criteria evaluated each performance measure in isolation. This new study proposed joint criteria considering the tradeoffs between performance measures such as cancer detection rate and recall rate.

Aunt Millie’s coverage of another BCSC studyExternal Web Site Policy, led by Tracy Onega, PhDExternal Web Site Policy, found that women who undergo mammography screening at breast centers with high volumes tend to have better outcomes. The study suggests that, “there may be volume benchmarks, and a low-volume facility may expect better outcomes if they bump up the number of mammograms read per year.”

Aunt Minnie also coveredExternal Web Site Policy the new BCSC study published September 28, 2015 in JAMA Internal Medicine, which provided the best evidence to date that CAD does not improve the accuracy of digital screening mammography but insurers are paying more for it - with no likely benefit.

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News & Announcements

The BCSC: 575 publications and counting

BCSC data have been published in over 575 papers since 1994. Reflecting the BCSC’s commitment to career development and data sharing, many have been led by non-BCSC and early-stage investigators. Topics have ranged from developing better risk prediction models to demonstrating that CAD adds costs, but is not effective at improving the accuracy of screening mammography.

The NIH-funded Program-Project, “Risk-Based Breast Cancer Screening in Community Settings,” recently completed its fourth year of funding and has published 43 manuscripts. Over 75 additional BCSC-related manuscripts are underway, with submissions planned during the next 1-2 years.

BCSC Researchers Organize Institute of Medicine Workshop

BCSC researchers were a strong presence at the May 2015 Institute of Medicine (IOM) Meeting,External Web Site Policy “Assessing and Improving Imaging Interpretation in Breast Cancer Screening.” Diana Buist, PhDExternal Web Site Policy, chaired the Workshop Planning Committee, and Diana Miglioretti PhDExternal Web Site Policy, Tracy Onega PhDExternal Web Site Policy and Patricia Carney, PhDExternal Web Site Policy (prior BCSC registry PI) served as members.

Presenters at the workshop included Diana Buist PhD, Berta Geller EdDExternal Web Site Policy, Louise Henderson PhD,External Web Site Policy Rebecca Hubbard PhDExternal Web Site Policy, Diana Miglioretti PhD, Tracy Onega PhD, and Patricia Carney PhD. The consensus committee found that while the technical quality of mammography had improved since MQSA implementation, mammography interpretation remained quite variable, and that this variability limited the full potential of mammography to reduce breast cancer mortality by detecting breast cancers at an early stage.

BCSC Researchers a Major Presence at the International Cancer Screening Network (ICSN)

Several BCSC researchers presented lectures and posters at the June International Cancer Screening Network (ICSN) annual meeting in the Netherlands.

  • Diana Miglioretti, PhDExternal Web Site Policy, gave a presentation on, “Identifying Women with Dense Breasts at High Risk for Interval Cancer.”
  • Rebecca Hubbard, PhDExternal Web Site Policy presented a poster, “Accounting for censoring in estimation of the cumulative risk of false-positive screening mammography results using observational data.”
  • Diana Miglioretti, PhD, presented a poster, “Radiation-Induced Breast Cancer and Breast Cancer death from Mammography Screening.”
  • Brian Sprague, PhDExternal Web Site Policy, presented a poster, “Potential Impact of Legislation Mandating Breast Density Notification: Benefits, Harms, and Cost Effectiveness of Supplemental Ultrasound Screening.”

The ICSN is a voluntary consortium of more than 30 countries that have active population-based cancer screening programs.

BCSC Research featured at the NCI Precision Cancer Symposium

The NCI Precision Cancer Symposium brought together experts in cancer screening, risk prediction, epidemiology, and other related disciplines to identify the most important questions in precision cancer screening and discuss how epidemiology can be used to find answers to these questions. Rebecca Hubbard, PhDExternal Web Site Policy led the “Evidence” topic with her presentation on, “Precision Breast Cancer Screening,” while Diana Miglioretti, PhDExternal Web Site Policy led a breakout session on, “Leveraging Existing Data Sources and Infrastructure.” The organizers plan to create a white paper summarizing the discussions and submit it to a peer-reviewed journal.

BCSC Researcher recipient of ACR Annual Meeting Gold-Merit Award

Amie Lee, MDExternal Web Site Policy, a BCSC Researcher from the University of Washington, won the American College of Radiology (ACR) Annual Meeting Gold-Merit Award for her e-poster abstract, Concordance of breast imaging reporting and data system assessments and management recommendations for breast MRI in community practiceExternal Web Site Policy.” As a recipient of this award, her abstract was published in the June 2015 online edition of the Journal of the American College of Radiology (JACR).

BCSC participates in the Cancer Epidemiology Descriptive Cohort Database (CEDCD)

The BCSC is a participating cohort in the National Cancer Institute’s Epidemiology and Genomics Research Program’s Cancer Epidemiology Descriptive Cohort Database (CEDCD). The CEDCD is a public database that presents descriptive information to the scientific community on cohorts studying cancer as a primary outcome. The purpose is to provide information on existing cohort infrastructures, to foster collaborations among interested scientists, to maximize cohort-based research, and increase transparency.

Diana Miglioretti gives Invited Lecture at the Netherlands Cancer Institute

Diana Miglioretti, PhDExternal Web Site Policy gave an invited lecture at the Netherlands Cancer InstituteExternal Web Site Policy reviewing the concept of risk-based cancer screening, which can improve screening efficiency by focusing on those more likely to benefit, and provided four examples of studies from the Breast Cancer Surveillance Consortium. The studies identified women who might benefit from earlier mammography screenings, annual screening or supplemental screenings, and women at highest risk of radiation-induced breast cancer from mammography.

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People News

Connie Lehman, MD PhD Connie Lehman, MD PhDExternal Web Site Policy is the new Director of Breast Imaging at Massachusetts General Hospital’s (MGH) Department of Radiology. Dr. Lehman has been recognized nationally and internationally for her clinical work, teaching and research. In addition to her new role at MGH, Dr. Lehman has begun a new position as Co-Director of Avon Comprehensive Breast Evaluation CenterExternal Web Site Policy as well as Professor of Radiology at Harvard Medical School. Dr. Lehman will continue leading the BCSC-P01 project, “Comparative Effectiveness of Imaging Strategies for Breast Cancer Screening in Community Practice.”

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The BCSC calculated 5-year risk using the updated BCSC Risk Calculator among women with, and without, breast cancer in the BCSC database. The sample consisted of 1,135,977 women aged 35 to 74 years old who had at least one mammogram with BI-RADS density reported between 1994 and 2010. The table shows the distributions of the 5-year risk and indicates that:

  • 75% of breast cancers have a BCSC 5-year risk of 1% or greater
  • 39% have a risk >1.67%, and
  • 20% of women without breast cancer have a BCSC 5-year risk >1.67%.

Distribution of BCSC risk in a screening population

bar chart showing the distribution of bcsc risk in a screening population [D]

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Recent BCSC Grant & Contract Awards

New Grant will Estimate Overdiagnosis in Cancer Screening Studies

The BCSC will provide data to estimate overdiagnosis associated with breast cancer screening for a new grant, led by Ruth Etzioni, PhDExternal Web Site Policy, and funded by the NCI. The study aims to advance knowledge about how to validly estimate overdiagnosis and to provide concrete information about overdiagnosis associated with specific cancer screening settings in order to inform screening policy development and clinical decision making.

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Recent BCSC Publications

Ayvaci MU, Alagoz O, Chhatwal J, Munoz del Rio A, Sickles EA, Nassif H, Kerlikowske K, Burnside ES. Predicting invasive breast cancer versus DCIS in different age groups. BMC Cancer 2014 Aug 11;14:584. doi: 10.1186/1471-2407-14-584. [View Abstract]

Gard CC, Aiello Bowles EJ, Miglioretti DL, Taplin SH, Rutter CM. Misclassification of Breast Imaging Reporting and Data System (BI-RADS) Mammographic Density and Implications for Breast Density Reporting Legislation. Breast J 2015 Sep-Oct;21(5):481-9. [View Abstract]

Hart V, Reeves KW, Sturgeon SR, Reich NG, Sievert LL, Kerlikowske K, Ma L, Shepherd J, Tice JA, Mahmoudzadeh AP, Malkov S, Sprague BL. The effect of change in body mass index on volumetric measures of mammographic density. Cancer Epidemiol Biomarkers Prev 2015 Nov;24(11):1724-30. [View Abstract]

Henderson LM, Benefield T, Marsh MW, Schroeder BF, Durham DD, Yankaskas BC, Bowling JM. The influence of mammographic technologists on radiologists' ability to interpret screening mammograms in community practice. Acad Radiol 2015 Mar;22(3):278-89. [View Abstract]

Henderson LM, Benefield T, Nyante SJ, Marsh MW, Greenwood-Hickman MA, Schroeder BF. Performance of digital screening mammography in a population-based cohort of black and white women. Cancer Causes Control 2015 Oct;26(10):1495-9. [View Abstract]

Henderson LM, Miglioretti DL, Kerlikowske K, Wernli KJ, Sprague BL, Lehman CM. Breast cancer characteristics associated with digital versus screen-film mammography for screen-detected and interval cancers. AJR Am J Roentgenol 2015 Sep;205(3):676-684. [View Abstract]External Web Site Policy

Henderson LM, O'Meara ES, Braithwaite D, Onega T; Breast Cancer Surveillance Consortium. Performance of digital screening mammography among older women in the United States. Cancer 2015 May 1;121(9):1379-86. [View Abstract]

Jackson SL, Abraham L, Miglioretti DL, Buist DS, Kerlikowske K, Onega T, Carney PA, Sickles EA, Elmore JG. Patient and Radiologist Characteristics Associated With Accuracy of Two Types of Diagnostic Mammograms. AJR Am J Roentgenol 2015 Aug;205(2):456-63. doi: 10.2214/AJR.14.13672. [View Abstract]

Kemp Jacobsen K, Abraham L, Buist DS, Hubbard RA, O'Meara ES, Sprague BL, Kerlikowske K, Vejborg I, Von Euler-Chelpin M, Njor SH. Comparison of cumulative false-positive risk of screening mammography in the United States and Denmark. Cancer Epidemiol 2015 Aug;39(4):656-63. [View Abstract]

Kemp Jacobsen K, O'Meara ES, Key D, S M Buist D, Kerlikowske K, Vejborg I, Sprague BL, Lynge E, von Euler-Chelpin M. Comparing sensitivity and specificity of screening mammography in the United States and Denmark. Int J Cancer 2015 Nov 1;137(9):2198-207. [View Abstract]

Kerlikowske K, Gard CC, Sprague BL, Tice JA, Miglioretti DL; Breast Cancer Surveillance Consortium. One versus Two Breast Density Measures to Predict 5- and 10-Year Breast Cancer Risk. Cancer Epidemiol Biomarkers Prev 2015 Jun;24(6):889-97. [View Abstract]

Kerlikowske K, Zhu W, Tosteson AN, Sprague BL, Tice JA, Lehman CD, Miglioretti DL; Breast Cancer Surveillance Consortium. Identifying women with dense breasts at high risk for interval cancer: a cohort study. Ann Intern Med 2015 May 19;162(10):673-81. doi: 10.7326/M14-1465. [View Abstract]

Lehman CD, Wellman RD, Buist DS, Kerlikowske K, Tosteson AN, Miglioretti DL; Breast Cancer Surveillance Consortium. Diagnostic Accuracy of Digital Screening Mammography With and Without Computer-Aided Detection. JAMA Intern Med 2015 Nov;175(11):1828-37. doi: 10.1001/jamainternmed.2015.5231. [View Abstract]

Lee CI, Bogart A, Germino JC, Goldman LE, Hubbard RA, Haas JS, Hill DA, Tosteson AN, Alford-Teaster JA, DeMartini WB, Lehman CD, Onega TL. Availability of Advanced Breast Imaging at Screening Facilities Serving Vulnerable Populations. J Med Screen 2016 Mar;23(1):24-30. [View Abstract]

Lee CI, Bogart A, Hubbard RA, Obadina ET, Hill DA, Haas JS, Tosteson AN, Alford-Teaster JA, Sprague BL, DeMartini WB, Lehman CD, Onega TL. Advanced Breast Imaging Availability by Screening Facility Characteristics. Acad Radiol 2015 Jul;22(7):846-52. [View Abstract]

Lee CI, Ichikawa L, Rochelle MC, Kerlikowske K, Miglioretti DL, Sprague BL, DeMartini WB, Wernli KJ, Joe BN, Yankaskas BC, Lehman CD. Breast MRI BI-RADS assessments and abnormal interpretation rates by clinical indication in US community practices. Acad Radiol 2014 Nov;21(11):1370-6. [View Abstract]

Lee JM, Buist DS, Houssami N, Dowling EC, Halpern EF, Gazelle GS, Lehman CD, Henderson LM, Hubbard RA. Five-year risk of interval-invasive second breast cancer. J Natl Cancer Inst 2015 Apr 22;107(7). pii: djv109. Print 2015 Jul. [View Abstract]

Miglioretti DL, Ichikawa L, Smith RA, Bassett LW, Feig SA, Monsees B, Parikh JR, Rosenberg RD, Sickles EA, Carney PA. Criteria for identifying radiologists with acceptable screening mammography interpretive performance on basis of multiple performance measures. AJR Am J Roentgenol 2015 Apr;204(4):W486-91. doi: 10.2214/AJR.13.12313. [View Abstract]

Onega T, Goldman LE, Walker RL, Miglioretti DL, Buist DS, Taplin S, Geller BM, Hill DA, Smith-Bindman R. Facility Mammography Volume in Relation to Breast Cancer Screening Outcomes. J Med Screen 2016 Mar;23(1):31-7. [View Abstract]

Scheel JR, Lee JM, Sprague BL, Lee CI, Lehman CD. Screening ultrasound as an adjunct to mammography in women with mammographically dense breasts. Am J Obstet Gynecol 2015 Jan;212(1):9-17. Review. [View Abstract]

Tejada JJ, Ivy J, King R, Wilson JR, Ballan MJ, Diehl K, Yankaskas B. Combined DES/SD model of breast cancer screening for older women, I: Natural-history simulation. IIE Transactions. Published Online 2014 Oct 30. [View Abstract]External Web Site Policy

Tice JA, Miglioretti DL, Li CS, Vachon CM, Gard CC, Kerlikowske K. Breast Density and Benign Breast Disease: Risk Assessment to Identify Women at High Risk of Breast Cancer. J Clin Oncol 2015 Oct 1;33(28):3137-43. [View Abstract]

Torres-Mejia G, Smith RA, Carranza-Flores Mde L, Bogart A, Martinez-Matsushita L, Miglioretti DL, Kerlikowske K, Ortega-Olvera C, Montemayor-Varela E, Angeles-Llerenas A, Bautista-Arredondo S, Sanchez-Gonzalez G, Martinez-Montanez OG, Uscanga-Sanchez SR, Lazcano-Ponce E, Hernandez-Avila M. Radiographers supporting radiologists in the interpretation of screening mammography: a viable strategy to meet the shortage in the number of radiologists. BMC Cancer 2015 May 16;15:410. doi: 10.1186/s12885-015-1399-2. [View Abstract]

van Ravesteyn NT, Stout NK, Schechter CB, Heijnsdijk EA, Alagoz O, Trentham-Dietz A, Mandelblatt JS, de Koning HJ. Benefits and harms of mammography screening after age 74 years: model estimates of overdiagnosis. J Natl Cancer Inst 2015 May 6;107(7). pii: djv103. Print 2015 Jul. [View Abstract]

van Ravesteyn NT, van Lier L, Schechter CB, Ekwueme DU, Royalty J, Miller JW, Near AM, Cronin KA, Heijnsdijk EA, Mandelblatt JS, de Koning HJ. Transition from film to digital mammography: impact for breast cancer screening through the national breast and cervical cancer early detection program. Am J Prev Med 2015 May;48(5):535-42. doi: 10.1016/j.amepre.2014.11.010. [View Abstract]

Wolf M, Krause J, Carney PA, Bogart A, Kurvers RH. Collective intelligence meets medical decision-making: the collective outperforms the best radiologist. PLoS One 2015 Aug 12;10(8):e0134269. eCollection 2015. [View Abstract]