Estimate of the Number of Breast Cancers Undetected by Screening Mammography in Individuals with Dense Breast Tissue
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Background: Screening mammography has limited sensitivity for detecting breast cancer in dense breast tissue. This study estimates the maximal number of breast cancers undetected by mammography in individuals with dense breast tissue participating in screening mammography in the United States. Methods: Published data on supplemental screening incremental cancer detection rates (ICDRs), dense breast tissue prevalence, and total annual screening mammography exams in the United States are utilized for study estimates. Results: Assuming an ICDR of 16 cancers beyond mammography per 1,000 individuals with dense breast tissue, 38.8 million mammograms in the U.S. in 2021, and a prevalence of dense breast tissue of 43%, the number of cancers undetected by mammography in individuals with dense breast tissue participating in screening in the U.S. is estimated at 267,000. Conclusion: A large number of undiagnosed breast cancers in the population of individuals with dense breast tissue participating in screening mammography is estimated.Keywords:
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Breast imaging is the newest, and according to most criteria the weakest, of all radiology subspecialties. Screening mammography in particular often loses money and is subsidized by other sections of the radiology department and occasionally, as in my own case, by direct hospital payments to breast imagers. Screening mammography is also the most common basis for lawsuits in radiology, which is not surprising, since 25 to 50% of cases of breast cancer are identified retrospectively on the previous annual screening mammogram. As the only quasi–public health endeavor in radiology, screening mammography is heavily regulated, with many unfunded mandates. Screening mammography, . . .
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Data derived from the first 30 months of operation of a low-cost mammography screening program demonstrate the impact of the introduction of low-cost screening on nearby mammography practices. Low-cost screening attracts a very different group of women than traditionally populate existing practices, and 93% represent "new business" rather than established mammography patients seeking examination at a lower price. Although low-cost screening does divert some women away from more expensive nearby practices, it also generates an approximately equal number of breast imaging cases for these neighbor practices, including problem-solving examinations to further evaluate screening-detected abnormalities and subsequent screening examinations for women who prefer more full-featured albeit costlier screening. Finally, a survey of nearby practices indicates that the introduction of low-cost screening had no measurable impact on the steadily increasing mammography case loads observed during the study period. Low-cost screening does not appear to be much of an economic threat to existing mammography practices, at least under the conditions in effect in the study area. It can indeed coexist successfully with traditional mammography practices that make no distinction in features and price between screening and problem-solving examinations.
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PURPOSE: To evaluate the effect of national breast cancer screening guidelines on current physician attitudes toward and practice of screening mammography. MATERIALS AND METHODS: Questionnaire responses from 278 physicians were analyzed. The questionnaire had four sections: general information on physician practice and experience, current use of breast cancer screening, perceptions of screening mammography, and physician awareness of and response to the controversy in breast cancer screening. RESULTS: In women aged 40-49 years, 144 (52%) of 278 physicians performed annual clinical breast examination and screening mammography every 2 years; 57 (21%) favored annual mammography and clinical breast examination. In women aged 50 years and older, 232 (83%) physicians screened patients annually with clinical breast examination and mammography. Two hundred seventeen (78%) physicians were aware of the recommended changes in screening guidelines; 54 (19%) were not aware of the changes. Of those aware of the changes, 56 (26%) changed to the new guidelines, 150 (69%) did not change, and six (3%) modified their practice somewhat. CONCLUSION: Physician practice as regards screening mammography is influenced by national guidelines.
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The age-adjusted incidence of breast cancer among Wisconsin women age 40 and older has increased by almost one third since the early 1980s. To estimate what portion of the observed increase in breast cancer incidence is due to mammography screening, we developed a model of the lead-time effect of this screening test and its impact on incidence. The model incorporates annual age-specific information including 1) the expected number of cases, 2) the rate of screening, 3) the detection ratio of screening mammography, and 4) the lead time of screening mammography. For women 40 years of age and older, the model predicts a 25% increase in incidence, compared with an observed increase of 28%. Overall, mammography screening explains 74% of the difference between the expected and observed number of cases over the study period. A greater portion of the increase in incidence among postmenopausal women is attributed to mammography screening than among younger women. The increase in the use of mammography appears to account for most but not all of the increased incidence of breast cancer in Wisconsin.
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Biennial service mammography screening for breast cancer has been offered to women aged 50-69 years in the municipality of Copenhagen since 1991. We report the results of the first three invitation rounds.Data were collected from the Copenhagen service mammography screening database and other Danish registers.The average participation rate during the first three invitation rounds was 66%. The breast cancer detection rate was 10/1,000 screened in the first invitation round and 5/1,000 in the consecutive rounds. The probability of a false positive mammography was 6% at the prevalent screen, and this was reduced to 3% at incidence screens. Fifty-two cases of interval cancer were seen after the first invitation round. The expected number was 152, which gives a proportional interval cancer rate of 0.34. The sensitivity was 86% and the specificity 94% after the first round.The detection rate of breast cancer was high, especially in the prevalence round. The trend in the incidence of breast cancer at the subsequent rounds was similar to that before screening, which indicates that mammography screening does not lead to any greater over-diagnosis. The rate of false positive mammography was high at the initial screening round, but was acceptable at subsequent rounds, and a false positive mammography does not seem to have affected participation in subsequent rounds. The Copenhagen screening programme conforms to international quality assurance guidelines for process evaluation.
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To the Editor.
—Dr Kerlikowske and colleagues1state in their introduction that "approximately 11% of screening mammographic examinations performed in the United States are interpreted as abnormal, requiring the requesting physician to assess the likelihood that the mammographic finding represents breast cancer." These authors conclude by encouraging "radiologists to use the Breast Imaging Reporting and Data System [BIRADS] assessment categories when reporting screening mammography results, so that primary care physicians can interpret such results and use LRs [likelihood ratios] to estimate a woman's likelihood of breast cancer after screening mammography." I do not agree with the assumption of this article that primary care physicians need to personally assess the likelihood of breast carcinoma after the detection of abnormalities at screening mammography, most of which are nonpalpable. In the great majority of instances, the decision to obtain additional imaging studies and/or perform biopsy is a mammographic rather than clinical decision. In those fewScreening mammography
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Background: Screening mammography has limited sensitivity for detecting breast cancer in dense breast tissue. This study estimates the maximal number of breast cancers undetected by mammography in individuals with dense breast tissue participating in screening mammography in the United States. Methods: Published data on supplemental screening incremental cancer detection rates (ICDRs), dense breast tissue prevalence, and total annual screening mammography exams in the United States are utilized for study estimates. Results: Assuming an ICDR of 16 cancers beyond mammography per 1,000 individuals with dense breast tissue, 38.8 million mammograms in the U.S. in 2021, and a prevalence of dense breast tissue of 43%, the number of cancers undetected by mammography in individuals with dense breast tissue participating in screening in the U.S. is estimated at 267,000. Conclusion: A large number of undiagnosed breast cancers in the population of individuals with dense breast tissue participating in screening mammography is estimated.
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Despite the lack of absolute confirmation from a properly controlled clinical trial, there is now sufficient evidence to permit the working assumption that screening mammography beginning at age 40 will play a substantial role in controlling breast cancer. An analysis of available data indicates that the benefits of mammographic screening far exceed potential risk, and that earlier detection of cancer will actually add years to life rather than simply permit an earlier diagnosis. American radiologists are now challenged to provide screening mammography in an easily accessible and inexpensive form, so that it is effectively available to all women over age 40.
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Digital Mammography
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