Pathways to breast cancer screening artificial intelligence algorithm validation

As more artificial intelligence (AI)-enhanced mammography screening tools enter the clinical market, greater focus will be placed on external validation in diverse patient populations. In this viewpoint, we outline lessons learned from prior efforts in this field, the need to validate algorithms on newer screening technologies and diverse patient populations, and conclude by discussing the need for a framework for continuous monitoring and recalibration of these AI tools. Sufficient validation and continuous monitoring of emerging AI tools for breast cancer screening will require greater stakeholder engagement and the creation of shared policies and guidelines

Are there racial/ethnic disparities among women younger than 40 undergoing mammography?

While the probability of a woman developing invasive breast cancer at age <40 is low (<1%), mammography use reported among younger women (age <40) is substantial, and varies by race/ethnicity. Little detail is known about mammography use among women aged <40, particularly by race/ethnicity. We describe racial/ethnic differences in: (1) mammography indication after considering underlying risk factors (breast symptoms and family history); (2) follow-up recommendations, and (3) mammography outcomes for first mammograms in women aged <40. These 1996–2005 Breast Cancer Surveillance Consortium data are prospectively pooled from seven U.S. mammography registries. Our community-based sample included 99,615 women aged 18–39 who self-reported race/ethnicity and presented for a first mammogram (screening or diagnostic) with no history of breast cancer. Multivariable analyses controlled for registry site, age, family history of breast cancer, symptoms, and exam year. Overall, 73.6% of the women in our sample were seen for a screening mammogram. Following screening mammography, African American (AA) women were more likely than white women to be recommended for additional workup [relative risk (RR): 1.15 (95% CI: 1.07–1.23)]. Following diagnostic mammography, AA [RR: 1.30 (95% CI: 1.17–1.44)] and Asian [RR: 1.44 (95% CI: 1.26–1.64)] women were more likely to be recommended for biopsy, fine-needle aspiration, or surgical consultation. Depending on race/ethnicity, and considering the rate of true positive to total first screening mammograms of younger women, a women has a likelihood of a true positive of 1 in 363–1,122; she has a likelihood of a false positive of 1 in 7–10. This study of community-based practice found racial/ethnic variability in mammography indication, recommendations, and outcomes among women undergoing first mammography before 40. These findings highlight important areas for future research to understand the motivating factors for these practice patterns and the implications of early mammography use

Cumulative Risk Distribution for Interval Invasive Second Breast Cancers After Negative Surveillance Mammography.

The aim of the current study was to characterize the risk of interval invasive second breast cancers within 5 years of primary breast cancer treatment. We examined 65,084 surveillance mammograms from 18,366 women with a primary breast cancer diagnosis of unilateral ductal carcinoma in situ or stage I to III invasive breast carcinoma performed from 1996 to 2012 in the Breast Cancer Surveillance Consortium. Interval invasive breast cancer was defined as ipsilateral or contralateral cancer diagnosed within 1 year after a negative surveillance mammogram. Discrete-time survival models—adjusted for all covariates—were used to estimate the probability of interval invasive cancer, given the risk factors for each surveillance round, and aggregated across rounds to estimate the 5-year cumulative probability of interval invasive cancer

Feasibility and Acceptability of Conducting a Randomized Clinical Trial Designed to Improve Interpretation of Screening Mammography

To describe recruitment, enrollment and participation in a study of U.S. radiologists invited to participate in a randomized controlled trial of two continuing medical education interventions designed to improve interpretation of screening mammography

Association Between Time Spent Interpreting, Level of Confidence, and Accuracy of Screening Mammography

To examine the effect of time spent viewing images and level of confidence on a screening mammography test set on interpretive performance

Diagnostic imaging and biopsy pathways following abnormal screen-film and digital screening mammography

The transition from screen-film to digital mammography may have altered diagnostic evaluation of women following a positive screening examination. This study compared use and timeliness of diagnostic imaging and biopsy for women screened with screen-film or digital mammography

Breast MRI in the Diagnostic and Preoperative Workup Among Medicare Beneficiaries With Breast Cancer

We compared the frequency and sequence of breast imaging and biopsy use for the diagnostic and preoperative workup of breast cancer according to breast MRI use among older women

Diagnosis of second breast cancer events after initial diagnosis of early stage breast cancer

To examine whether there are any characteristics of women or their initial tumors that might be useful for tailoring surveillance recommendations to optimize outcomes. We followed 17,286 women for up to 5 years after an initial diagnosis of ductal carcinoma in situ (DCIS) or early stage (I/II) invasive breast cancer diagnosed between 1996 and 2006. We calculated rates per 1,000 women years of recurrences and second breast primaries relative to demographics, risk factors, and characteristics of initial diagnosis: stage, treatment, mode of initial diagnosis. Nearly 4% had a second breast cancer event (314 recurrences and 344 second breast primaries). Women who used adjuvant hormonal therapy or were ≥80 years had the lowest rates of second events. Factors associated with higher recurrence and second primary rates included: initial DCIS or stage IIB, estrogen/progesterone receptor-negative, younger women (<50 years). Women with a family history or greater breast density had higher second primary rates, and women who received breast conserving surgery without radiation had higher recurrence rates. Roughly one-third of recurrences (37.6%) and second primaries (36.3%) were not screen-detected. Initial mode of diagnosis was a predictor of second events after adjusting for age, stage, primary treatment, and breast density. A recent negative mammogram should not falsely reassure physicians or women with new breast symptoms or changes because one-third of second cancers were interval cancers. This study does not provide any evidence in support of changing surveillance intervals for different subgroups

Establishing a Gold Standard for Test Sets. Variation in Interpretive Agreement of Expert Mammographers

Test sets for assessing and improving radiologic image interpretation have been used for decades and typically evaluate performance relative to gold-standard interpretations by experts. To assess test sets for screening mammography, a gold-standard for whether a woman should be recalled for additional work-up is needed, given that interval cancers may be occult on mammography and some findings ultimately determined to be benign require additional imaging to determine if biopsy is warranted. Using experts to set a gold-standard assumes little variation occurs in their interpretations, but this has not been explicitly studied in mammography

Radiologists' Attitudes and Use of Mammography Audit Reports

The U.S. Mammography Quality Standards Act (MQSA) mandates medical audits to track breast cancer outcomes data associated with interpretive performance. The objectives of our study were to assess the content and style of audits and examine use of, attitudes toward, and perceptions of the value that radiologists' have regarding mandated medical audits