In Reply: As Dr Fujita points out, our study showed that supplemental ultrasound screening increased the cancer detection rate. To achieve this, recall rates increased from 10.2% to 20.3% on average (16.8% with incidence screenings). While a benchmark mammography recall rate of 10% has been suggested, acceptable benchmarks for combined screening with other modalities have not been established.
We agree with Fujita that a better management strategy for sonographically detected BI-RADS 3 lesions, as well as BI-RADS 4a, is needed. In year 1, of 2637 mammogram results, 177 (6.7%) were BI-RADS 3 (including 1 cancer), as were 401 (15.2%) mammography plus ultrasound results (4 malignancies).1 In additional analyses from this study, we found that, in part due to the elevated risk of our participants, nearly 17% of sonographically BI-RADS 3 lesions underwent biopsy and 0.8% proved to be malignant. For sonographically BI-RADS 4a lesions, the biopsy rate was 82.5% with 2.8% proving to be malignant. BI-RADS 3 and BI-RADS 4a ultrasound lesions together accounted for 71.1% of biopsies in our study. Multiple similar benign-appearing masses that should be classified as BI-RADS 2, benign, were frequent among BI-RADS 3 lesions. Adding elastography, a measure of stiffness, can reduce unnecessary biopsy of sonographically BI-RADS 4a masses.2 With any screening strategy, continued monitoring of outcomes and physician education can help reduce unnecessary recall and biopsy.
Berg WA, Barr RG, Zhang Z. Supplementary Imaging for Breast Cancer Screening in High-Risk Women—Reply. JAMA. 2012;308(3):236. doi:10.1001/jama.2012.7549
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