Radiological Screening for Breast Cancer

8/14/2019 Radiological Screening for Breast Cancer

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Brittany Lee, HMS IVBrittany Lee, HMS IV

Dr. Gillian LiebermanDr. Gillian Lieberman

Why screen for breast cancer?Why screen for breast cancer? Does screening reduce breast cancer mortality?Does screening reduce breast cancer mortality?

How should average risk women be screened?How should average risk women be screened? When do we start screening?When do we start screening? Is there a difference between digital and filmIs there a difference between digital and film

mammography?mammography?

When is breast MR appropriate?When is breast MR appropriate? Is there a role for MRI to screen the contralateralIs there a role for MRI to screen the contralateral

breast in patients with a new diagnosis of breastbreast in patients with a new diagnosis of breastcancer?cancer?

Is breast MRI better for screening high risk women?Is breast MRI better for screening high risk women?

Our patient: 54F presents for screeningOur patient: 54F presents for screening

mammographymammography


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Screening CriteriaScreening Criteria The ConditionThe Condition

Must be important health problem.Must be important health problem. Epidemiology and natural history of the disease should be adequately understood.Epidemiology and natural history of the disease should be adequately understood. Must have a detectable risk factor, disease marker, latent period or early symptomaticMust have a detectable risk factor, disease marker, latent period or early symptomatic

stage.stage. The TestThe Test

Simple, safe, precise and validated screening test.Simple, safe, precise and validated screening test.

Acceptable to the populationAcceptable to the population TreatmentTreatment

The treatment/intervention for patients identified through screening must be effectiveThe treatment/intervention for patients identified through screening must be effectiveand early treatment must improve outcomes compared to late treatment.and early treatment must improve outcomes compared to late treatment.

Agreed policy on who to treat.Agreed policy on who to treat. Screening programScreening program

RCT must demonstrate that screening reduced morbidity and mortality.RCT must demonstrate that screening reduced morbidity and mortality. The benefit of screening must outweigh the risks/side effects from the screening.The benefit of screening must outweigh the risks/side effects from the screening. Facilities for diagnosis and treatment should be available.Facilities for diagnosis and treatment should be available. The total cost of finding a case should be economically balanced in relation to medicalThe total cost of finding a case should be economically balanced in relation to medical

expenditure as a whole.expenditure as a whole. Case-finding should be a continuous process.Case-finding should be a continuous process.

Wilson and Jungner1968


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Early evidence for screeningEarly evidence for screening

The decision to embark on national screeningThe decision to embark on national screeningprograms in the US and UK were based on the RRprograms in the US and UK were based on the RRreduction in breast cancer specific mortality ofreduction in breast cancer specific mortality ofthese two early trials.these two early trials.

Trial Location Year Age N= Median

follow-up

RRreduction

Absolute riskreduction

HIP* New York 1963 40-64 31,000 pairs 16 years 21% 0.14%

TwoCountry

Sweden 1977 40-74 77,000 Study

56,000 Control

17 years 32% 0.18%

*Health Insurance Plan

*Health Insurance Plan

Gotzsche and Nielsen. Cochrane Review. 20Gotzsche and Nielsen. Cochrane Review. 20Humphrey et al. Ann Intern Med. 2002.Humphrey et al. Ann Intern Med. 2002.


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Current evidence for screeningCurrent evidence for screeningHumphrey et al. Ann Intern Med. 2002.Humphrey et al. Ann Intern Med. 2002.

Meta-analyses of seven RCT (Edinburgh excluded)Meta-analyses of seven RCT (Edinburgh excluded)concluded mammography reduces breast cancerconcluded mammography reduces breast cancermortality rates in women age 40-74mortality rates in women age 40-74


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Relative vs. Absolute RiskRelative vs. Absolute Risk

Example: A patient with cancer is trying to decide whether toExample: A patient with cancer is trying to decide whether toundergo radiation treatment (XRT) to reduce their risk of aundergo radiation treatment (XRT) to reduce their risk of arecurrence. Besides the side effects of treatment, XRT isrecurrence. Besides the side effects of treatment, XRT iscumbersome requiring treatments 5 days a week for 6 weeks. XRTcumbersome requiring treatments 5 days a week for 6 weeks. XRTreduces the risk of recurrence by 75%!!reduces the risk of recurrence by 75%!!

A relative risk reduction of 75% is relative to the risk of recurrence.A relative risk reduction of 75% is relative to the risk of recurrence.

If the risk of recurrence without XRT is 20%:If the risk of recurrence without XRT is 20%: Risk of recurrence with XRT = 20% - 20% * 0.75 = 5%Risk of recurrence with XRT = 20% - 20% * 0.75 = 5%

Absolute risk reduction of XRT = 20% - 5% = 15%Absolute risk reduction of XRT = 20% - 5% = 15%

If the risk of recurrence without XRT is 4%:If the risk of recurrence without XRT is 4%: Risk of recurrence with XRT = 4% - 4% * 0.75 = 1%Risk of recurrence with XRT = 4% - 4% * 0.75 = 1% Absolute risk reduction of XRT = 4% - 1% = 3%Absolute risk reduction of XRT = 4% - 1% = 3%


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Mammography vs. AdjuvantMammography vs. Adjuvant

ChemotherapyChemotherapyBerry et al. NEJM. 2007.Berry et al. NEJM. 2007.

Since the variability between the models was greaterSince the variability between the models was greaterfor screening than treatment, there is greaterfor screening than treatment, there is greateruncertainty when estimating the benefit of screening.uncertainty when estimating the benefit of screening.


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Screening only has a benefit if followed by adjuvant treatmentScreening only has a benefit if followed by adjuvant treatment

Mammography vs. AdjuvantMammography vs. Adjuvant

ChemotherapyChemotherapyBerry et al. NEJM. 2007.Berry et al. NEJM. 2007.

Reductionin

mortalitywith

adjuvant tx

alone

Noreductionin

mortalitywith

screeningalone


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Screening QuestionedScreening QuestionedGotzsche and Nielsen. Cochrane Review. 2006Gotzsche and Nielsen. Cochrane Review. 2006

Meta-analysis of the seven RCTs (same Humphrey)Meta-analysis of the seven RCTs (same Humphrey) The Edinburgh trial was excludedThe Edinburgh trial was excluded Two trials were adequately randomized (best)Two trials were adequately randomized (best) Four trials were suboptimally randomizedFour trials were suboptimally randomized

Overall RR reduction = 20%Overall RR reduction = 20% For the best trials:For the best trials:

RR reduction = 15%RR reduction = 15% Absolute risk reduction is 0.05%Absolute risk reduction is 0.05%

Screening leads to overdiagnosis andScreening leads to overdiagnosis andovertreatment:overtreatment: RR increase = 30%RR increase = 30% Absolute risk increase = 0.5%Absolute risk increase = 0.5%


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Screening QuestionedScreening QuestionedGotzsche and Nielsen. Cochrane Review. 2006Gotzsche and Nielsen. Cochrane Review. 2006

Conclusion:Conclusion: For every 2000 women screened over 10For every 2000 women screened over 10

years, one will have her life prolonged and 10years, one will have her life prolonged and 10healthy women will be diagnosed with breasthealthy women will be diagnosed with breastcancer and treated unnecessarily.cancer and treated unnecessarily.

It is not clear whether screening does moreIt is not clear whether screening does moregood than harm.good than harm.


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Guidelines for screeningGuidelines for screening

For average risk women with lifetime risk 70: screen with mammography if life expectancy isscreen with mammography if life expectancy is

>10 yrs>10 yrs

For high risk women with lifetime risk >20-25%:For high risk women with lifetime risk >20-25%: Includes BRCA1/BRCA2 mutations, women with a strong FHxIncludes BRCA1/BRCA2 mutations, women with a strong FHx

of breast or ovarian cancer, and women who were treatedof breast or ovarian cancer, and women who were treatedwith mantle radiation for Hodgkins lymphomawith mantle radiation for Hodgkins lymphoma

Screen with MRI as adjunct to mammography starting at ageScreen with MRI as adjunct to mammography starting at age40 or 10 years before the diagnosis of a first degree relative40 or 10 years before the diagnosis of a first degree relative

Saslow et al. CA Cancer J Clin. 2007.


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Cost-effectiveness of screeningCost-effectiveness of screening

AgeAge Cost per year of life savedCost per year of life saved 40-4940-49 $105,000$105,000

50-6950-69 $21,400$21,400 >65 to 75 or 80>65 to 75 or 80 $34,000-$88,000$34,000-$88,000

For the 40-49 and the 50-69 age group,For the 40-49 and the 50-69 age group,

screening is cost-effectivescreening is cost-effective Screening is cost-effective in the oldestScreening is cost-effective in the oldest

age group if the women are healthy.age group if the women are healthy.

Salzmann et al. Ann Intern Med. 1997Mandelblatt et al. Ann Intern Med. 200


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Digital vs. Film MammographyDigital vs. Film MammographyPisano et al. NEJM. 2005.Pisano et al. NEJM. 2005.

Study Design:Study Design: Prospective study: 49,528 asymptomatic women underwentProspective study: 49,528 asymptomatic women underwent

both digital and film screening mammographyboth digital and film screening mammography

Methods:Methods: Mammograms were interpreted by using the BIRADS systemMammograms were interpreted by using the BIRADS system

and malignancy scaleand malignancy scale Breast cancer status was ascertained by breast biopsy or by f/uBreast cancer status was ascertained by breast biopsy or by f/u

mammography at > 10 m.mammography at > 10 m. Sensitivity and specificity was calculated at 365 and 455 days.Sensitivity and specificity was calculated at 365 and 455 days. For malignancy scale, ROC analysis was performed.For malignancy scale, ROC analysis was performed.

Results/Conclusion:Results/Conclusion: The accuracy of digital mammography was significantly higherThe accuracy of digital mammography was significantly higher

than film for women < 50 yo, women with dense breasts onthan film for women < 50 yo, women with dense breasts onmammography andmammography andpre- and perimenopausal womenpre- and perimenopausal women

B itt L HMS IV


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Our patient: 54F presents for screeningOur patient: 54F presents for screening

mammographymammography Her risk factors for breast cancer:Her risk factors for breast cancer: Gender and ethnicityGender and ethnicity Estrogen exposure:Estrogen exposure:

Menarche at age 11Menarche at age 11

P2G2 with first pregnancy at age 34P2G2 with first pregnancy at age 34 PremenopausalPremenopausal

No personal history of breast cancerNo personal history of breast cancer Family history of post-menopausal breast cancerFamily history of post-menopausal breast cancer

in mother and paternal aunt, not Ashkenaziin mother and paternal aunt, not Ashkenaziethnicityethnicity

By the Gail Model, her lifetime risk of BC isBy the Gail Model, her lifetime risk of BC is

17.6%17.6% Case courtesy of Dr. Valerie Fein-Zachary

B i L HMS IVB itt L HMS IV


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Is mammography appropriateIs mammography appropriate

screening for this patient?screening for this patient?

Yes, her lifetime risk is


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B itt L HMS IVB itt L HMS IV


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BI-RADS mammography categoriesBI-RADS mammography categories

0: Need additional imaging0: Need additional imaging 1: Negative, routine follow-up1: Negative, routine follow-up 2: Benign, routine follow-up2: Benign, routine follow-up 3: Probably benign finding3: Probably benign finding

Follow-up with diagnostic view of the suspicious lesion in sixFollow-up with diagnostic view of the suspicious lesion in six

monthsmonths Probability of malignancy is 2 percentProbability of malignancy is 2 percent

4: Suspicious4: Suspicious Core-needle biopsy or needle localization biopsy as soon asCore-needle biopsy or needle localization biopsy as soon as

possiblepossible >2 to 95 percent risk of malignancy>2 to 95 percent risk of malignancy Stratified further as:Stratified further as:

(a) Low-risk(a) Low-risk (b) Intermediate-risk(b) Intermediate-risk (c) Moderate to high-risk(c) Moderate to high-risk

5: Highly suggestive of malignancy5: Highly suggestive of malignancy Core-needle biopsy or needle localization biopsy as soon asCore-needle biopsy or needle localization biopsy as soon as

possiblepossible >95 percent risk of malignancy>95 percent risk of malignancy

6: Biopsy-proven carcinoma6: Biopsy-proven carcinoma

B itt L HMS IVBrittany Lee HMS IV


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Fletcher.UpToDate. 2007.

Brittan Lee HMS IVBrittany Lee HMS IV


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4 m later, she palpates a mass in her left4 m later, she palpates a mass in her left

breastbreast Mammography is repeated:Mammography is repeated:

Brittany Lee HMS IVBrittany Lee HMS IV


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4 m later, she palpates a mass in her left4 m later, she palpates a mass in her left

breastbreast Mammography is repeated:Mammography is repeated:

BI-RADS 4c



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DDx of a breast massDDx of a breast mass

Carcinoma of theCarcinoma of thebreastbreast

Phyllodes tumorPhyllodes tumor

FibroadenomaFibroadenoma

Adenoma of the nippleAdenoma of the nipple Intraductal papillomaIntraductal papilloma

Carcinoma of the breastCarcinoma of the breast

Benign calcifications in:Benign calcifications in: SkinSkin

ArteriesArteries CystsCysts

Fibroadenoma with denseFibroadenoma with densepopcorn-like calcificationspopcorn-like calcifications

Foreign body post-traumaForeign body post-trauma

DDx of a calcifications

on mammography



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An ultrasound guided core biopsy reveals ainfiltrating ductal carcinoma and DCIS



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Use of MRI to screen the contralateralUse of MRI to screen the contralateral

breast after an initial BC diagnosisbreast after an initial BC diagnosisLehman et al. NEJM. 2007.Lehman et al. NEJM. 2007. Study design:Study design:

Prospective study of 969 women with a recent diagnosis ofProspective study of 969 women with a recent diagnosis ofunilateral breast cancer, who had no abnormalities onunilateral breast cancer, who had no abnormalities onclinical exam or mammography in the contralateral breast,clinical exam or mammography in the contralateral breast,

underwent breast MRunderwent breast MR Results:Results:

12.5% had positive MRI findings12.5% had positive MRI findings 25% with a positive MRI were positive for cancer25% with a positive MRI were positive for cancer 3.1% had contralateral BC detected by MRI3.1% had contralateral BC detected by MRI

Conclusion:Conclusion: MRI can detect clinically and mammographically occult BCMRI can detect clinically and mammographically occult BC

in the contralateral breast after a new diagnosis of breastin the contralateral breast after a new diagnosis of breastcancer.cancer.



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Breast MRI techniqueBreast MRI technique

Without contrast: Density, architecture,Without contrast: Density, architecture,fluid-filled structures and implantsfluid-filled structures and implants

Contrast, gadolinium, is used toContrast, gadolinium, is used tomaximize cancer detection.maximize cancer detection.

Contrast agents improve detection sinceContrast agents improve detection since

malignant tumors are hypervascular andmalignant tumors are hypervascular andenhance early (before normal breastenhance early (before normal breasttissue) after contrast is given.tissue) after contrast is given.



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http://www.qcif.edu.au/industry/QldXRay.html



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Benign breast findings on MRIBenign breast findings on MRI

Fibroadenoma Lactating breast Implant with bubbleT2 Post-contrast T1 No contrast T1 Post-contrast

www.mrsc.ucsf.edu/breast/picts_of_breast_mri.ht



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Malignant findings on MRIMalignant findings on MRI

T1 Pre-contrast IDC T1 Post-contrast IDC

T1 Pre-contrast DCIS T1 Post-contrast DCIS

www.mrsc.ucsf.edu/breast/picts_of_breast_mri.ht

Brittany Lee HMS IVBrittany Lee, HMS IV


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Our patients breast MRIOur patients breast MRI

Right Breast Left Breast



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Breast MRI is better for screening high riskBreast MRI is better for screening high risk

womenwomen Multiple studies demonstrate that breast MR is moreMultiple studies demonstrate that breast MR is more

sensitive than mammography for high risk women*sensitive than mammography for high risk women*

Kriege et al. NEJM 2004:Kriege et al. NEJM 2004: 1909 women with lifetime risk >15% were screened every 61909 women with lifetime risk >15% were screened every 6

month with clinical breast exam (CBE) and every year withmonth with clinical breast exam (CBE) and every year withmammography (M) and MRImammography (M) and MRI

Median f/u of 2.9 yearsMedian f/u of 2.9 years Results:Results:

Sensitivity was 79.5% MRI, 33.3% M and 17.9% CBESensitivity was 79.5% MRI, 33.3% M and 17.9% CBE

Specificity was 89.8% MRI, 95% M and 98.1% CBESpecificity was 89.8% MRI, 95% M and 98.1% CBE Conclusion:Conclusion:MRI is more sensitive than mammography inMRI is more sensitive than mammography in

detecting tumors in women with an inherited susceptibilitydetecting tumors in women with an inherited susceptibilityto breast cancer.to breast cancer.

*Leach et al. Lancet. 2005.

Lehman et al. Radiology. 2007.

Kriege et al. NEJM. 2004.

Kuhl et al. J Clin Oncol. 2005.



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Brittany Lee, HMS IVy ,


Our patient: SummaryOur patient: Summary 54F with average risk for breast cancer had a benign findings on a54F with average risk for breast cancer had a benign findings on a

screening mammogramscreening mammogram 4 months later, she p/w a left breast mass4 months later, she p/w a left breast mass U/S guided bx of the L lesion revealed IDC and DCISU/S guided bx of the L lesion revealed IDC and DCIS Breast MRI of the contralateral breast showed a suspicious lesionBreast MRI of the contralateral breast showed a suspicious lesion

in the right posterior breastin the right posterior breast MR-guided bx the R lesion revealed IDC and DCISMR-guided bx the R lesion revealed IDC and DCIS No evidence of metastatic disease was seen on full-body CT andNo evidence of metastatic disease was seen on full-body CT and

bone scanbone scan Underwent bilateral mastectomy:Underwent bilateral mastectomy:

Right total mastectomy with sentinel node biopsyRight total mastectomy with sentinel node biopsy Left modified radical mastectomy since grossly positive axillary nodesLeft modified radical mastectomy since grossly positive axillary nodes

were found intraoperativelywere found intraoperatively

Pathology:Pathology: Right: IDC 0.9 cm, grade I with LVI positive and 1:1 sentinel nodesRight: IDC 0.9 cm, grade I with LVI positive and 1:1 sentinel nodes

positive. Histology was ER/PR+ and HER-2/neu negative.positive. Histology was ER/PR+ and HER-2/neu negative. Left: IDC >7 cm, grade 3 with LVI positive and 5:9 axillary nodesLeft: IDC >7 cm, grade 3 with LVI positive and 5:9 axillary nodes

positive.positive.

Histology was ER/PR+ and HER-2/neu positive.Histology was ER/PR+ and HER-2/neu positive.

Case courtesy of Dr. Valerie Fein-Zachary



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ConclusionConclusion Does screening reduce breast cancer mortality?Does screening reduce breast cancer mortality?

Uncertain since although 7 RCTs show that screening reduces theUncertain since although 7 RCTs show that screening reduces therelative risk of breast cancer mortality by 15-20%, not all of these trialsrelative risk of breast cancer mortality by 15-20%, not all of these trialswere randomized well and the absolute risk reduction was only 0.05-were randomized well and the absolute risk reduction was only 0.05-0.1%0.1%

How should average risk women be screened?How should average risk women be screened? Guidelines suggest to consider mammography screening at age 40 andGuidelines suggest to consider mammography screening at age 40 and

recommends to start everyone at age 50.recommends to start everyone at age 50. Digital mammography is more accurate at detecting breast cancer thanDigital mammography is more accurate at detecting breast cancer than

filmfilm

When do I use breast MRI?When do I use breast MRI? Screening for women >20% lifetime risk of breast cancerScreening for women >20% lifetime risk of breast cancer Evaluation of the ipsilateral breast for synchronous lesions in a womenEvaluation of the ipsilateral breast for synchronous lesions in a women

with a newly diagnosed breast cancer that is believed to be morewith a newly diagnosed breast cancer that is believed to be moreextensive than seen on standard imagingextensive than seen on standard imaging

Evaluation of the contralateral breast for occult disease in women withEvaluation of the contralateral breast for occult disease in women witha unilateral breast cancer that had no clinical or mammographica unilateral breast cancer that had no clinical or mammographicabnormalities on the opposite sideabnormalities on the opposite side

Women with mammographically occult primary disease with anWomen with mammographically occult primary disease with anadenocarcinoma of unknown primary site in the axillary nodesadenocarcinoma of unknown primary site in the axillary nodes



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ReferencesReferences

Berry DA, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. NEJM. 2005. 353;Berry DA, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. NEJM. 2005. 353;17: 1784-92.17: 1784-92. Boyd NF, et al. Mammographic density and the risk and Detection of Breast Cancer. NEJM. 2007. 356; 3:Boyd NF, et al. Mammographic density and the risk and Detection of Breast Cancer. NEJM. 2007. 356; 3:

227-36.227-36. Fletcher SW. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst. 1993.Fletcher SW. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst. 1993.

85; 20: 1644-56.85; 20: 1644-56. Fletcher SW. Screening average risk women for breast cancer. 2007. UptoDate.Fletcher SW. Screening average risk women for breast cancer. 2007. UptoDate. Glass AG, et al. Breast cancer incidence, 1980-2006: combined roles of menopausal hormone therapy,Glass AG, et al. Breast cancer incidence, 1980-2006: combined roles of menopausal hormone therapy,

screening mammography, and estrogen receptor status. J Natl Cancer Inst. 2007. 99; 15: 1152-61.screening mammography, and estrogen receptor status. J Natl Cancer Inst. 2007. 99; 15: 1152-61. Gotzsche PC and Nielsen M. Screening for breast cancer with mammography. Cochrane Database ofGotzsche PC and Nielsen M. Screening for breast cancer with mammography. Cochrane Database of

Systematic Review. 2006. 4.Systematic Review. 2006. 4. Humphrey LL, et al. Breast cancer screening: a summary of the evidence for the U.S. Preventive ServicesHumphrey LL, et al. Breast cancer screening: a summary of the evidence for the U.S. Preventive ServicesTask Force. Ann Intern Med. 2002. 137; 5 Part 1: 347-60.Task Force. Ann Intern Med. 2002. 137; 5 Part 1: 347-60.

Jemal A, et al. Cancer statistics from SEER, CA Cancer J Clin. 2007. 55; 1: 43-66.Jemal A, et al. Cancer statistics from SEER, CA Cancer J Clin. 2007. 55; 1: 43-66. Kriege M, et al. Efficacy of MRI and mammography for breast-cancer screening in women with a familial orKriege M, et al. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or

genetic predisposition. NEJM. 2004. 35; 5:427-37.genetic predisposition. NEJM. 2004. 35; 5:427-37. Lehman CD, et al. MRI Evaluation of the contralateral breast in women with recently diagnosed breastLehman CD, et al. MRI Evaluation of the contralateral breast in women with recently diagnosed breast

cancer. NEJM. 2007. 356; 13: 1295-1303.cancer. NEJM. 2007. 356; 13: 1295-1303. Mandelblatt J, et al. The cost-effectiveness of screening mammography beyond age 65. Ann Intern Med.Mandelblatt J, et al. The cost-effectiveness of screening mammography beyond age 65. Ann Intern Med.

2003. 139:835.2003. 139:835. Macura KJ, et al. Patterns of Enhancement on Breast MR Images: Interpretation and Imaging Pitfalls.Macura KJ, et al. Patterns of Enhancement on Breast MR Images: Interpretation and Imaging Pitfalls.

Radiographics. 2006. 26:1719-34.Radiographics. 2006. 26:1719-34. Pisano ED, et al. Diagnostic performance of digital vs. film mammography for breast-cancer screening.Pisano ED, et al. Diagnostic performance of digital vs. film mammography for breast-cancer screening.

NEJM. 2005. 353; 17: 1773-83.NEJM. 2005. 353; 17: 1773-83. Ravdin PM, et al. The decrease in breast-cancer incidence in 2003 in the United States. NEJM. 2007. 356;Ravdin PM, et al. The decrease in breast-cancer incidence in 2003 in the United States. NEJM. 2007. 356;

16: 1670-74.16: 1670-74. Salzmann P, et al. Cost-effectiveness of extending screening mammography guidelines to include womenSalzmann P, et al. Cost-effectiveness of extending screening mammography guidelines to include women

40-49 years of age. Ann Intern Med. 1997. 127:955.40-49 years of age. Ann Intern Med. 1997. 127:955. Saslow D, et al. American cancer society guidelines for breast screening with MRI as an adjunct toSaslow D, et al. American cancer society guidelines for breast screening with MRI as an adjunct to

mammography. CA Cancer J Clin. 2007. 57; 2: 75-89.mammography. CA Cancer J Clin. 2007. 57; 2: 75-89.



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AcknowledgementsAcknowledgements

Residents:Residents: Katie KrajewskiKatie Krajewski

Anne KimAnne Kim Senthil PalaniappunSenthil Palaniappun Andrew BennettAndrew Bennett

Dr. Valerie Fein-ZacharyDr. Valerie Fein-Zachary Dr. Gillian LiebermanDr. Gillian Lieberman Maria LevantakisMaria Levantakis

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Radiological Screening for Breast Cancer