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Original Contribution
May 14, 2008

Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer

Author Affiliations

Author Affiliations: American Radiology Services Inc, Johns Hopkins Green Spring, Lutherville, Maryland (Dr Berg); Center for Statistical Sciences, Brown University, Providence, Rhode Island (Drs Blume and Cormack and Ms Marques); Feinberg School of Medicine, Northwestern University, Chicago, Illinois (Dr Mendelson); CERIM, Buenos Aires, Argentina (Dr Lehrer); Weinstein Imaging Associates, Pittsburgh, Pennsylvania (Dr Böhm-Vélez); University of North Carolina School of Medicine, Chapel Hill (Dr Pisano); University of Toronto, Sunnybrook and Women's Hospital, Toronto, Ontario, Canada (Dr Jong); University of Texas Southwestern Medical Center, Dallas (Dr Evans); Mayo Clinic, Rochester, Minnesota (Dr Morton); University of Cincinnati, Cincinnati, Ohio (Dr Mahoney); Keck School of Medicine, University of Southern California, Los Angeles (Dr Larsen); Forum Health, Western Reserve Care System, Youngstown, Ohio (Dr Barr); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri (Dr Farria); American College of Radiology, Philadelphia, Pennsylvania (Ms Boparai).

JAMA. 2008;299(18):2151-2163. doi:10.1001/jama.299.18.2151

Context Screening ultrasound may depict small, node-negative breast cancers not seen on mammography.

Objective To compare the diagnostic yield, defined as the proportion of women with positive screen test results and positive reference standard, and performance of screening with ultrasound plus mammography vs mammography alone in women at elevated risk of breast cancer.

Design, Setting, and Participants From April 2004 to February 2006, 2809 women, with at least heterogeneously dense breast tissue in at least 1 quadrant, were recruited from 21 sites to undergo mammographic and physician-performed ultrasonographic examinations in randomized order by a radiologist masked to the other examination results. Reference standard was defined as a combination of pathology and 12-month follow-up and was available for 2637 (96.8%) of the 2725 eligible participants.

Main Outcome Measures Diagnostic yield, sensitivity, specificity, and diagnostic accuracy (assessed by the area under the receiver operating characteristic curve) of combined mammography plus ultrasound vs mammography alone and the positive predictive value of biopsy recommendations for mammography plus ultrasound vs mammography alone.

Results Forty participants (41 breasts) were diagnosed with cancer: 8 suspicious on both ultrasound and mammography, 12 on ultrasound alone, 12 on mammography alone, and 8 participants (9 breasts) on neither. The diagnostic yield for mammography was 7.6 per 1000 women screened (20 of 2637) and increased to 11.8 per 1000 (31 of 2637) for combined mammography plus ultrasound; the supplemental yield was 4.2 per 1000 women screened (95% confidence interval [CI], 1.1-7.2 per 1000; P = .003 that supplemental yield is 0). The diagnostic accuracy for mammography was 0.78 (95% CI, 0.67-0.87) and increased to 0.91 (95% CI, 0.84-0.96) for mammography plus ultrasound (P = .003 that difference is 0). Of 12 supplemental cancers detected by ultrasound alone, 11 (92%) were invasive with a median size of 10 mm (range, 5-40 mm; mean [SE], 12.6 [3.0] mm) and 8 of the 9 lesions (89%) reported had negative nodes. The positive predictive value of biopsy recommendation after full diagnostic workup was 19 of 84 for mammography (22.6%; 95% CI, 14.2%-33%), 21 of 235 for ultrasound (8.9%, 95% CI, 5.6%-13.3%), and 31 of 276 for combined mammography plus ultrasound (11.2%; 95% CI. 7.8%-15.6%).

Conclusions Adding a single screening ultrasound to mammography will yield an additional 1.1 to 7.2 cancers per 1000 high-risk women, but it will also substantially increase the number of false positives.

Trial Registration clinicaltrials.gov Identifier: NCT00072501