Breast Disease

Mammography has long been recognized as the most effective cancer screening modality. Nevertheless, substantial numbers of women either do not utilize mammography or do not do so in compliance with recommended screening guidelines. A substantial body of literature has been published that discusses strategies likely to be effective in increasing mammography screening. Health care provider recommendation for a mammogram is the single most effective intervention. This paper reviews the more recent literature to highlight a selection of the additional strategies that are most likely to be effective among all women, and among women of various vulnerable cultural and population subgroups. African American, Hispanic, Pacific Asian, and Native American communities are included in the discussion. The paper also addresses other communities with special needs, such as those who are lesbians, elderly, low users of health services, and those who are physically or mentally challenged.

The use of routine mammography screening is associated with earlier breast cancer detection and decreased mortality. Several researchers have identified mammographers as potentially effective agents for encouraging patients to engage in routine screening. Mammographers are particularly well situated within the health care system to address patients’ knowledge, psychological, and cultural barriers to routine screening. Few opportunities exist, however, for mammographers to acquire skills in providing culturally-sensitive patient education and emotional assessment to help women overcome such barriers. In 1997 the North Carolina Breast Cancer Screening Program (NC-BCSP) developed and implemented an innovative, two-hour training program to help mammographers address the educational and psychosocial needs of rural, African American women in eastern North Carolina. NC-BCSP’s extensive survey data (n = 2000), as well as qualitative data from 25 focus groups conducted with more than 200 rural African American women, were used to develop a curriculum titled Expanding the Role of Mammographers. It was the first American Society of Radiologic Technologists (ASRT) accredited training program for mammographers in North Carolina that solely addressed psychosocial topics. The curriculum emphasized mammographers’ potential impact on women’s attitudes and behavioral intentions, and taught communication strategies to enhance mammographer-patient interaction. It included supplemental learning materials, skill-building exercises, and patient education materials to assist participants in applying new skills and knowledge. Of the 33 mammographers invited to the training, 19 attended. A structured evaluation form, completed by 18 participants, conveyed positive reactions to the intervention. This training workshop was conducted as part of NC-BCSP’s much larger, community-based intervention; as such, it was not independently evaluated. NC-BCSP’s broader intervention appears to be associated, however, with positive population-level changes in breast cancer awareness and mammography use.

Studies of the effectiveness of breast cancer screening for women in their forties show that the probability of benefit is relatively small and, for some women, may be outweighed by the probability of harm. Thus, screening for breast cancer in this age group is a close call on which reasonable women may disagree. Many women in their forties, however, are being screened. We suggest that few truly understand the issues involved in this decision. In this paper, we examine the potential benefits and harms of breast cancer screening for women ages 4049 and consider a strategy for helping women make informed decisions about screening: shared decision making. Shared decision making involves framing breast cancer screening as a decision that could reasonably be decided either for or against screening; giving the patient evidence-based information about the decision in an understandable format; and assisting the patient to use her values to close on a decision. We believe that this approach will eventually become the standard of care not only for breast cancer screening for women in their forties, but for older women (and other issues), as well.

In contrast to incidence rates prevailing in women in Western countries, Chinese women in Taiwan and China are considered to have the lowest incidence of breast cancer in the world. However, in the past 20 years, breast cancer incidence in Chinese women has seen a dramatic increase of 50100%, which strongly supports the need for breast cancer prevention and screening programs. It is also important to indicate that breast cancer in Chinese women is characterized by younger age at tumor onset. More than 50% of the total breast cancer diagnosed annually is found in premenopausal patients, creating the need to initiate breast cancer screening programs in this population. Initially, the breast cancer screening program depended on breast self-examination. Since Chinese women have relatively small breasts, it was assumed that breast cancer was easier to detect by self-examination. However, this strategy has failed. The dilemma of breast cancer screening can be summarized by the fact that Chinese have a rapidly increasing incidence of premenopausal breast cancer, while the overall incidence is still low. Therefore, since premenopausal women have denser breasts than postmenopausal women, and Chinese women have smaller breasts and a higher percentage of dense breasts, increased mammography screening frequency may be not the sole solution to increase detection in this age group. In our experience in Taiwan, the addition of breast ultrasound may be helpful. Nearly all the nonpalpable cancers detected by mammography in our women are due to microcalcifications, and ultrasound is more sensitive in detecting nonpalpable cancers; Therefore, we suggest that a screening program, based on ultrasound to detect nonpalpable cancers not associated with microcalcifications, along with mammography within a long period, may provide more effective protection for Taiwanese and Chinese women against breast cancer.

Percutaneous image-guided core breast biopsy is faster, less invasive, less deforming, and less expensive than surgical biopsy for diagnosing nonpalpable breast lesions. Percutaneous biopsy may be performed using different imaging guidance modalities (e.g., stereotaxis or ultrasound) and different tissue acquisition devices (e.g., automated needles or vacuum-assisted biopsy probes). Stereotactic biopsy may be used for all lesion types (masses and calcifications). Stereotactic 14-gauge automated core biopsy spared a surgical procedure in 76–85% of cases, decreasing the cost of diagnosis by 40–56%. Annual national savings from use of stereotactic 14-gauge automated core biopsy rather than surgical biopsy for nonpalpable lesions would exceed $100 million.

Stereotactic 11-gauge vacuum-assisted biopsy yields significant improvement in diagnosis of calcifications and may be used in lesions that are not amenable to stereotactic 14-gauge automated core biopsy. Stereotactic 11-gauge vacuum-assisted biopsy spared a surgical procedure in 76% cases, decreasing cost of diagnosis by 20%. Use of stereotactic 11-gauge vacuum-assisted biopsy for calcifications and for nonpalpable masses not amenable to stereotactic 14-gauge automated core biopsy would yield annual national savings exceeding $50 million. Ultrasound-guided biopsy, used primarily for masses, has several advantages including speed, comfort, lack of radiation exposure, and real-time needle visualization.

Ultrasound-guided core biopsy spared a surgical procedure in 85% cases, decreasing the cost of diagnosis by 56%. Although both ultrasound-guided core biopsy and stereotactic biopsy are less expensive than surgery, cost savings are greater for ultrasound-guided core biopsy. An annual national savings over $50 million could be realized with the use of ultrasound-guided core biopsy for nonpalpable masses. Future work should include evaluating the emerging new technologies for percutaneous breast biopsy and optimizating the choice of biopsy method for different clinical scenarios. Society may benefit from cost reduction as women benefit from a faster, less invasive, and less deforming approach to diagnosis.

The commitment to the goal of diagnosing and treating breast cancer at its earliest point of development remains strong. As a result, biopsy techniques continue to evolve. Freehand needle localizations were supplanted by fenestrated grids and hook wires. In the 1990s, stereotactic and ultrasound guided large core needle biopsy techniques were introduced, and now ultrasound and stereotactic guided vacuum-assisted procedures with 11-gauge needles are commonplace. Most recently, very large core needle biopsy devices were developed with a purpose of percutaneously diagnosing and treating nonpalpable breast lesions. However, bigger may not necessarily be better. This paper reviews the very large core needle biopsy technique and compares it to traditional large core needle biopsy. Factors such as technical success, histologic concordance, surgical margin positivity and cost are discussed.

Mammographic local staging of invasive carcinoma and DCIS begins during diagnostic mammography before the first biopsy intervention and continues through the wire localization, excision, and pathologic evaluation of the entire extent of the lesion. Better understanding of the limitations of mammographic staging can direct future research and development. For the evaluation of pre-existing or novel local staging techniques for breast carcinoma, outcomes not only include breast cancer overall survival and disease-free survival, but local recurrence after breast conservation treatment as well as the need for re-excision after primary excision.

The Mammography Quality Standards Act (MQSA) took the voluntary peer review process of the American College of Radiology (ACR) Mammography Accreditation Program (MAP) and used it for the foundation of a stringent set of federal regulations. By mandating accreditation, certification, and inspection for all providers, the legislative objective was to assure American women that they have the equal opportunity for quality breast cancer screening no matter where they reside. However, as with any government regulation there is an inherent cost to the regulated community. This article will address the need for regulation, the positive impact and the additional burdens that have resulted.

On January 28, 2000, the U.S. Food and Drug Administration (FDA) approved the first full-field digital mammography unit for clinical use. The approval occurred approximately ten years after a National Cancer Institute (NCI) expert panel determined that, of all emergent technologies, digital mammography held the greatest potential for improving breast cancer detection [1,2]. Currently, four types of digital mammographic systems are under clinical evaluation. This article will review the information from the early clinical trials on digital mammography and will attempt to define the potential impact of digital mammography on the clinical practice of breast imaging.

This paper describes the American College of Radiology Imaging Network (ACRIN), a new National Cancer Institute cooperative group, formed to perform multicenter clinical trials in diagnostic imaging and imaging-guided therapeutic technologies. The administrative structure of the organization and the mechanism by which trials are considered and approved for support are detailed. The advantages of this funding mechanism over previous NCI efforts are discussed. Detailed descriptions of the breast imaging protocols that ACRIN will open in the near future are provided. The quality of radiology as an academic discipline is likely to improve due to the infrastructure and training provided by this new organization.