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Original Investigation
July 1, 2019

Strategies to Identify Women at High Risk of Advanced Breast Cancer During Routine Screening for Discussion of Supplemental Imaging

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 3General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco
  • 4Departments of Surgery and Radiology, University of Vermont, Burlington
  • 5The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 6Norris Cotton Cancer Center, Lebanon, New Hampshire
  • 7Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
  • 8Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago
  • 9Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 10Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill
  • 11Department of Public Health Sciences, University of California, Davis
JAMA Intern Med. Published online July 1, 2019. doi:10.1001/jamainternmed.2019.1758
Key Points

Question  Which women with dense breasts undergoing routine screening are at high risk of advanced breast cancer?

Findings  In this cohort study of 638 856 women, high rates of advanced breast cancer occurred in women with heterogeneously dense breasts and a 5-year risk of 2.5% or higher and those with extremely dense breasts and a 5-year risk of 1.0% or higher. Identification of density-risk subgroups at high risk of advanced cancer provided the most efficient approach for targeting women for supplemental imaging discussions (1097 discussions per potential advanced cancer prevented).

Meaning  Assessment of 5-year risk in women with dense breasts identified subgroups at highest risk of advanced cancer and was a more efficient strategy for supplemental imaging discussions than was targeting all women with dense breasts.

Abstract

Importance  Federal legislation proposes requiring that screening mammography reports to practitioners and women incorporate breast density information and that women with dense breasts discuss supplemental imaging with their practitioner given their increased risk of interval breast cancer. Instead of discussing supplemental imaging with all women with dense breasts, it may be more efficient to identify women at high risk of advanced breast cancer who may benefit most from supplemental imaging.

Objective  To identify women at high risk of advanced breast cancer to target woman-practitioner discussions about the need for supplemental imaging.

Design, Setting, and Participants  This prospective cohort study assessed 638 856 women aged 40 to 74 years who had 1 693 163 screening digital mammograms taken at Breast Cancer Surveillance Consortium (BCSC) imaging facilities from January 3, 2005, to December 31, 2014. Data analysis was performed from October 10, 2018, to March 20, 2019.

Exposures  Breast Imaging Reporting and Data System (BI-RADS) breast density and BCSC 5-year breast cancer risk.

Main Outcomes and Measures  Advanced breast cancer (stage IIB or higher) within 12 months of screening mammography; high advanced cancer rates (≥0.61 cases per 1000 mammograms) defined as the top 25th percentile of advanced cancer rates, and discussions per potential advanced cancer prevented.

Results  A total of 638 856 women (mean [SD] age, 56.5 [8.9] years) were included in the study. Women with dense breasts (heterogeneously or extremely dense) accounted for 47.0% of screened women and 60.0% of advanced cancers. Low advanced cancer rates (<0.61 per 1000 mammograms) occurred in 34.5% of screened women with dense breasts. High advanced breast cancer rates occurred in women with heterogeneously dense breasts and a 5-year risk of 2.5% or higher (6.0% of screened women) and those with extremely dense breasts and a 5-year risk of 1.0% or higher (6.5% of screened women). Density-risk subgroups at high advanced cancer risk comprised 12.5% of screened women and 27.1% of advanced cancers. Density-risk subgroups had the fewest supplemental imaging discussions per potential advanced cancer prevented compared with a strategy based on dense breasts (1097 vs 1866 discussions). Women with heterogeneously dense breasts and a 5-year risk less than 1.67% (21.7% of screened women) had high rates of false-positive short-interval follow-up recommendation without undergoing supplemental imaging.

Conclusions and Relevance  The findings suggest that breast density notification should be combined with breast cancer risk so women at highest risk for advanced cancer are targeted for supplemental imaging discussions and women at low risk are not. BI-RADS breast density combined with BCSC 5-year risk may offer a more efficient strategy for supplemental imaging discussions than targeting all women with dense breasts.

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