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Understanding Factors That Affect Mammography Performance: Contribution of the BCSC
Bonnie C. Yankaskas, PhDProfessor of RadiologyUniversity of North Carolina at Chapel Hill
For the BCSC
Early mammography and knowledge in 1995
1920-1960 Most work related to techniqueThere were a few papers – three factors that affect the breast image: positioning
agemenstrual status
1963 mammography became nationally recognized as a tool for breast imaging but great variation in quality and radiation dosage
1972 first dedicated film-screen system on the market1992 40% of mammography facilities fully accredited (voluntary)
1994 only MQSA certified facilities could offer mammography
1995 mammography screening still young, but more widely usedresearch was focused on clinical use, and technique
………………………We knew that:: Age, breast pattern, and menstrual status may be
related to accuracy of interpretation
Definitions
Acad Radiol 2000; 7:1058-1068
•Standardized definitions• What is a screening mammogram?• What is a positive mammogram?• What pathology constitutes cancer?• When is a cancer associated with a mammogram• How long do we follow mammograms to determine accuracy
• Developed operational approaches to measurement
Cancer associated with assessments
Age 25-79 yrs
0
10
20
30
40
50
60
70
80
90
100
25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Sen% Spec% PPV % Recall %
Performance measures increase with age except recall rates which decreaseYounger women have same pattern as women 40 and older, but with a steeper slope for decrease in recall and increase in sensitivity (small numbers of cancers)
http://Breastscreening.cancer.gov,
Yankaskas et al. JNCI 2010
Sensitivity by Family Hx by Age
0
10
20
30
40
50
60
70
80
90
100
30-39 40-49 50-59 60-69
fam hx +
fam hx -
Specificity by Family Hx by Age
0
10
20
30
40
50
60
70
80
90
100
30-39 40-49 50-59 60-69
fam hx +
fam hx -
Family History
No statistical association of family history with sensitivity
Significant lower specificity with positive family history compared to no family history
Kerlikowske et al. Ann Intern Med 2000
Density, HT, and Age
(Carney et al, Ann Intern Med 2003) • For dense and not dense breasts, sensitivity increases with increasing age• At each age group, sensitivity increases with decreasing breast density. • HT not an independent predictor of accuracy; most likely affects accuracy by increasing breast density. •Same pattern for specificity
Not dense, No HRT
Not dense, HRT
Dense, No HRT
Dense, HRT
Augmentation Status
N % (95% CI)
Sensitivity Cancer
+ augment 31 51.6 (33.1-69.8)
- augment 198 73.1 (66.3-79.2)
Specificity No cancer
+ augment 9,876 96.6 (96.2-97.0)
- augment 905,269 96.1 (96.0-96.1)
Miglioretti et al. JAMA 2004
Sensitivity lower with little or no change in specificity in presence of augmentation
Yankaskas et al., Radiology 2005
Frequency in Months Since Previous Mammogram
One year
Two years
Three years
Time Since Previous Mammogram
0
20
40
60
80
100
Sens Spec PPV Recall
pe
rce
nt
9-15 16-20 21-27 >28 No prev
Yankaskas et al., 2005
All measures except specificity increase with time since previous mammogram, specificity decreases.
Change In Overall Accuracy Over Time
Has accuracy improved over the years that the BCSC has been collecting data?
100%
60% 15%
0%
1996 1997 1998 1999 2000 2001 2002 2003 2004
Calendar Year
80%
5%
10%
Change in accuracy measures 1996-2004
Specificitysensitivity PPV
Specificity decreased, Sensitivity and PPV increased over time, controlling for risk factors
Ichikawa et al., 2010
Then and Now
Age
Density
Family History
Hormone Therapy
Age/Density/HT
Breast Augmentation
Time between screens
Location
Comparison Films
Radiologist volume
Double reading
Obesity
Race- B/W Asia
Benchmarks
Change over time
Definitions
What we knew in 1995 – Age, density patterns, positioning, menstrual cycle
What we know now 2010
Study year
Region of country, community
?
Access
Radiologist characteristics and training
Patient characteristics and behaviors
?Technologists?
Cancer incidence
FACTORS THAT AFFECT MAMMOGRAPHY PERFORMANCE
Technical quality of study
Facility characteristics and organization
?
Future work on accuracy in community practice
Factors affecting digital performance Factors affecting MRI and other advanced technologists Role of technologist on accuracy Factors for biomarkers in screening Effect of changes of improvements in present
technology, or use of technology Review standard definitions for new modalities Comparing technologies
THANK YOU andThanks to our community partners:
Patients, Technologists,
RadiologistsAdministrators
and our funding partnersNational Cancer Institute
and American Cancer Society
References for published articles0. http://breastscreening.cancer.gov1. Carney PA, Miglioretti DL, Yankaskas BC, Kerlikowske K, Rosenberg R, Rutter CM, Geller BM, Abraham LA,
Taplin SH, Dignan M, Cutter G, Ballard-Barbash R. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003;138(3):168-175.
2. Elmore JG, Carney PA, Abraham LA, Barlow WE, Egger JR, Fosse JS, Cutter GR, Hendrick RE, D'Orsi CJ, Paliwal P, Taplin SH. The association between obesity and screening mammography accuracy. Arch Intern Med 2004;164(10):1140-1147.
3. Gill KS, Yankaskas BC. Screening mammography performance and cancer detection among black women and white women in community practice. Cancer 2004;100(1):139-148.
4. Kerlikowske K, Carney PA, Geller B, Mandelson MT, Taplin SH, Malvin K, Ernster V, Urban N, Cutter G, Rosenberg R, Ballard-Barbash R. Performance of screening mammography among women with and without a first-degree relative with breast cancer. Ann Intern Med 2000;133(11):855-863.
5. Kerlikowske K, Creasman J, Leung JW, Smith-Bindman R, Ernster VL. Differences in screening mammography outcomes among white, chinese, and filipino women. Arch Intern Med 2005;165(16):1862-1868.
6. Kerlikowske K, Walker R, Miglioretti DL, Desai A, Ballard-Barbash R, Buist DS. Obesity, mammography use and accuracy, and advanced breast cancer risk. J Natl Cancer Inst 2008;100(23):1724-1733.
7. Miglioretti DL, Rutter CM, Geller BM, Cutter G, Barlow WE, Rosenberg R, Weaver DL, Taplin SH, Ballard-Barbash R, Carney PA, Yankaskas BC, Kerlikowske K. Effect of breast augmentation on the accuracy of mammography and cancer characteristics. JAMA 2004;291(4):442-450.
8. Rosenberg RD, Kelsey CA, Williamson MR, Houston JD, Hunt WC. Computer-based collection of mammographic exposure data for quality assurance and dosimetry. Med Phys 2001;28(8):1546-1551.
9. Rosenberg RD, Yankaskas BC, Abraham LA, Sickles EA, Lehman CD, Geller BM, Carney PA, Kerlikowske K, Buist DS, Weaver DL, Barlow WE, Ballard-Barbash R. Performance benchmarks for screening mammography. Radiology 2006;241(1):55-66.
10. Schell MJ, Yankaskas BC, Ballard-Barbash R, Qaqish BF, Barlow WE, Rosenberg RD, Smith-Bindman R. Evidence-based target recall rates for screening mammography. Radiology 2007;243(3):681-689.
11. Yankaskas BC, Cleveland RJ, Schell MJ, Kozar R. Association of recall rates with sensitivity and positive predictive values of screening mammography. AJR Am J Roentgenol 2001;177(3):543-549.
12. Yankaskas BC, Taplin SH, Ichikawa L, Geller BM, Rosenberg RD, Carney PA, Kerlikowske K, Ballard-Barbash R, Cutter GR, Barlow WE. Association between Mammography Timing and Measures of Screening Performance in the United States. Radiology 2005;234(2):363-373.
It is all about magic!
Spring in Oslo
Summer in Alaska
0.000.100.200.300.400.500.600.700.800.901.00
0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14
Recall Proportion
Se
nsi
tiv
ity Practices with recall
rate between 4.9% and 5.5% achieve the best trade off between sensitivity and PPV
Association of sensitivity and PPV to recall rate
Yankaskas et al. 2005
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