Understanding Factors That Affect Mammography Performance: Contribution of the BCSC

1. Understanding Factors That Affect Mammography Performance: Contribution of the BCSC Bonnie C. Yankaskas, PhD Professor of Radiology University of North Carolina at Chapel Hill For the BCSC

2. Early mammography and knowledge in 1995 1920-1960 Most work related to technique There were a few papers – three factors that affect the breast image: positioning age menstrual 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 market 1992 40% of mammography facilities fully accredited (voluntary) 1994 only MQSA certified facilities could offer mammography 1995 mammography screening still young, but more widely used research was focused on clinical use, and technique ……………………… We knew that:: Age, breast pattern, and menstrual status may be related to accuracy of interpretation

3. 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

4. Cancer associated with assessments

5. Age 25-79 yrs Yankaskas et al. JNCI 2010 http://Breastscreening.cancer.gov, Performance measures increase with age except recall rates which decrease Younger 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)

6. 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

7. Density, HT, and Age Not dense, No HRT Not dense, HRT Dense, No HRT Dense, HRT (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

8. Augmentation Status Miglioretti et al. JAMA 2004 Sensitivity lower with little or no change in specificity in presence of augmentation

9. Frequency in Months Since Previous Mammogram One year Two years Three years Yankaskas et al., Radiology 2005

10. Time Since Previous Mammogram Yankaskas et al., 2005 All measures except specificity increase with time since previous mammogram, specificity decreases.

11. Change In Overall Accuracy Over Time Has accuracy improved over the years that the BCSC has been collecting data?

12. Change in accuracy measures 1996-2004 • Specificity • sensitivity  PPV Specificity decreased, Sensitivity and PPV increased over time, controlling for risk factors Ichikawa et al., 2010

13. 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 Then and Now What we knew in 1995 – Age, density patterns, positioning, menstrual cycle What we know now 2010

14. FACTORS THAT AFFECT MAMMOGRAPHY PERFORMANCE Technical quality of study Radiologist characteristics and training Facility characteristics and organization Access Study year ? Cancer incidence ? Patient characteristics and behaviors Region of country, community ?Technologists?

15. 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

16. THANK YOU and Thanks to our community partners: Patients, Technologists, Radiologists Administrators and our funding partners National Cancer Institute and American Cancer Society

17. References for published articles 0. http://breastscreening.cancer.gov 1. 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.

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21. Association of sensitivity and PPV to recall rate Practices with recall rate between 4.9% and 5.5% achieve the best trade off between sensitivity and PPV Yankaskas et al. 2005