Hot topics from Arizona - well you would expect that wouldn"t you!

Last week was the 9th International Workshop on Digital Mammography in Tuscon, Arizona.

Most of the papers given are already online - at SpringerLink

Hot topics were Tomosynthesis, Dual Energy mammography - some using subtraction techniques, and others using contrast enhancement.

John Boone, a physicist from UC Davis in Sacramento also was describing his experience with Breast CT using a cone beam - good for resolution, equivalent radiation dose, but not so good for calcifications.

Mammography screening of the elderly - controversies

Last month a paper was published in the Journal of Clinical Oncology entitled - Mammography Before Diagnosis Among Women Age 80 Years and Older With Breast Cancer from MD Anderson Cancer Center in Texas.

The study found that among those who had a mammogram every year or two before their diagnosis, 68 percent found the cancer at an early stage, compared with 33 percent of those who skipped mammograms altogether.

Their conclusion was that regular mammography among women > or = to 80 years of age was associated with earlier disease stage, although improved survival remains difficult to demonstrate. Health care providers should consider discussing the potential benefits of screening mammography with their older patients, particularly for those without significant comorbidity.

This sparked coverage by the New York Times, which did a good job of presenting the pros and cons of screening the elderly. Considering that the end point for measuring a screening program is mortality reduction, then it should be looked at in a proper light rather than just concentrating on reducing morbidity from the disease.

We have the occasional patient in San Francisco having screening mammograms in their eighties, similar to the NHS BSP in the UK, where patients can self refer. With the rising elderly population, and better breast-awareness, it may well be that we do more mammography in the elderly and reduce morbidity than we do for now.

FDA relaxes rules on FFDM regulation - could enable new technologies to get to the market quicker

The FDA have made an announcement that would reclassify FFDM systems from the current class III category, which requires premarket approval (PMA) applications, to class II, which requires the less rigorous 510(k) process. The reclassification would eliminate or reduce the requirement for vendors to conduct large-scale multireader, multicase (MRMC) clinical trials prior to submitting applications for equipment approval.

If the proposal is adopted, the FDA will rely upon well-designed bench studies and limited clinical testing in lieu of large-scale MRMC clinical studies. Products using new technology, with dissimilar designs from approved systems, or having indications for use that are dissimilar from legally marketed devices of the same type, may be required to collect additional clinical data.

An MRMC study may be required to compare sensitivity, specificity, and receiver operating characteristic curves if the results of physical laboratory testing and mammographic feature analysis raise concerns by the FDA.

Vendors have been quick to respond, even with comments that the CR mammography market, particularly in Europe will not be affected due to the initial fast and extensive uptake of CR, but that newer technologies will get to market sooner. This is reflected in the announcement by Hologic, that they plan to have a device for tomosynthesis released at RSNA in 2009.

However, tomosynthesis may need to be subject to a large trial like the DMIST study, as it's eventual aim is to become the main screening tool for breast cancer detection.

MRI increases mastectomy rate

Two interesting stories hit the headlines this week. The first concerned breast density, and the fact that passing through the menopause can greatly affect the rate at which a woman's mammographic (breast) density changes over time.
This was a report from the American Journal of Epidemiology
Am. J. Epidemiol. 2008 167: 1027-1036



The researchers retrieved and digitized 5698 mammograms from 1689 women who were imaged in 1990-2003 to evaluate PD in the Minnesota Breast Cancer Family cohort. The women completed two questionnaires, the first in 1990-1996 and the second in 2001, which provided extensive risk factor data. Postmenopausal women showed a decline in PD of 1.0% over a mean of 6.2 years, while premenopausal women showed a decline in PD of 1.8% over a mean of 4.0 years.

Further analysis showed that, before the age of 50 years, postmenopausal women who never used hormones had a higher PD compared with former and current users. After the age of 50 years, women who never used hormones had larger declines in PD than current or former users.

Higher BMI was associated with lower PD among postmenopausal women at any age after adjusting for covariates. And women in the 95th (highest) percentile for baseline PD showed greater declines in PD over time than women in the 5th (lowest) percentile.

You can get a FREE PDF of the paper from - here

The other story was widely reported in the NEW YORK TIMES this Friday. Thanks to press releases, details about the study which will be presented in Chicago at the annual meeting of the American Society of Clinical Oncology, which begins May 30 has got into the media.

The study revealed that "the percentage of women opting for mastectomy rather than lumpectomy began rising sharply after 2003." A possible explanation for the increase is that MRI "detects more possibly cancerous growths than mammography," which "could be causing patients and doctors to conclude that a lumpectomy, which removes just the part of the breast containing the primary tumor, may not be sufficient."

We certainly are doing far more MRIs, but in our case at UCSF, many of these patients are in trials. Wait until we start following the American Cancer Society Guidelines for women at high risk of breast cancer, with the increase in false positives we get, plus the increased anxiety because of family history...........

Ultrasound screening in HIGH RISK WOMEN - article in JAMA May 2008

Wendy Berg and her ACRIN group published the results of Combined Screening With Ultrasound and Mammography vs Mammography Alone in high risk women in JAMA.

The ACRIN study in full is listed here

The JAMA abstract is here

Conclusions Adding a single screening ultrasound to mammography will yield an additional 1.1 to 7.2 cancers per 1000 high-risk women, but it will also substantially increase the number of false positives.

Breast cancer risk and aspirin use - report from the National Cancer Institute

Nonsteroidal anti-inflammatory drugs and breast cancer risk in the National Institutes of Health-AARP Diet and Health Study

Gretchen L Gierach, James V Lacey Jr, Arthur Schatzkin, Michael F Leitzmann, Douglas Richesson, Albert R Hollenbeck, Louise A Brinton
Breast Cancer Research 2008, 10:R38 (30 April 2008)
Available online through breast cancer research

Conclusions
Breast cancer risk was not significantly associated with NSAID use, but daily aspirin use was associated with a modest reduction in ER-positive breast cancer. Our results provide support for further evaluating relationships by NSAID type and breast cancer subtype.

This story hit the headlines in the USA last night, with several analyses on NBC news. Overall the reaction and advice was sensible, but yet again we will have more questions to answer when we see our patients this week

NEW BIRADS FAQs released by the ACR

While we discuss the pros and cons of some of our 1-5 grading systems, the American College of Radiologists has released an updated FAQ about the BIRADS classification system for breast imaging, widely used in Europe as well as North America.

Here is the link to the PDF file