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

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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