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

Early mammography and knowledge in 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 % 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

Definitions Acad Radiol 2000; 7: 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 yrs 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) Yankaskas et al. JNCI 2010

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) SensitivityCancer + augment ( ) - augment ( ) SpecificityNo cancer + augment9, ( ) - augment905, ( ) 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 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?

Change in accuracy measures Specificity sensitivity  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 and Thanks to our community partners: Patients, Technologists, Radiologists Administrators and our funding partners National Cancer Institute and American Cancer Society

References for published articles 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): 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): Gill KS, Yankaskas BC. Screening mammography performance and cancer detection among black women and white women in community practice. Cancer 2004;100(1): 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): 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): 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): 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): 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): 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): 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): 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): 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):

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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