Radiological review of prior screening mammograms of screen-detected breast cancer

Tone Hovda, Kaitlyn Tsuruda, Solveig Roth Hoff, Kristine Kleivi Sahlberg, Solveig Hofvind, Tone Hovda, Kaitlyn Tsuruda, Solveig Roth Hoff, Kristine Kleivi Sahlberg, Solveig Hofvind

Abstract

Objective: To perform a radiological review of mammograms from prior screening and diagnosis of screen-detected breast cancer in BreastScreen Norway, a population-based screening program.

Methods: We performed a consensus-based informed review of mammograms from prior screening and diagnosis for screen-detected breast cancers. Mammographic density and findings on screening and diagnostic mammograms were classified according to the Breast Imaging-Reporting and Data System®. Cases were classified based on visible findings on prior screening mammograms as true (no findings), missed (obvious findings), minimal signs (minor/non-specific findings), or occult (no findings at diagnosis). Histopathologic tumor characteristics were extracted from the Cancer Registry of Norway. The Bonferroni correction was used to adjust for multiple testing; p < 0.001 was considered statistically significant.

Results: The study included mammograms for 1225 women with screen-detected breast cancer. Mean age was 62 years ± 5 (SD); 46% (567/1225) were classified as true, 22% (266/1225) as missed, and 32% (392/1225) as minimal signs. No difference in mammographic density was observed between the classification categories. At diagnosis, 59% (336/567) of true and 70% (185/266) of missed cancers were classified as masses (p = 0.004). The percentage of histological grade 3 cancers was higher for true (30% (138/469)) than for missed (14% (33/234)) cancers (p < 0.001). Estrogen receptor positivity was observed in 86% (387/469) of true and 95% (215/234) of missed (p < 0.001) cancers.

Conclusions: We classified 22% of the screen-detected cancers as missed based on a review of prior screening mammograms with diagnostic images available. One main goal of the study was quality improvement of radiologists' performance and the program. Visible findings on prior screening mammograms were not necessarily indicative of screening failure.

Key points: • After a consensus-based informed review, 46% of screen-detected breast cancers were classified as true, 22% as missed, and 32% as minimal signs. • Less favorable prognostic and predictive tumor characteristics were observed in true screen-detected breast cancer compared with missed. • The most frequent mammographic finding for all classification categories at the time of diagnosis was mass, while the most frequent mammographic finding on prior screening mammograms was a mass for missed cancers and asymmetry for minimal signs.

Keywords: Breast neoplasm; Digital mammography; Female; Mammography; Mass screening.

Conflict of interest statement

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Figures

Fig. 1
Fig. 1
Review procedure
Fig. 2
Fig. 2
a, b True screen-detected breast cancer. A 57-year-old woman presenting with an irregular mass in the medial aspect of the left breast at screening (arrow), diagnosed with a 17-mm invasive carcinoma of no special type. Left craniocaudal view at diagnosis (a) and at prior screening (b). c, d Missed screen-detected breast cancer. A 67-year-old woman presenting with a spiculated mass in the upper lateral part of the right breast at screening (arrow), diagnosed with an 18-mm invasive lobular carcinoma. Right mediolateral oblique (MLO) view at diagnosis (c). A spiculated mass at the later cancer site (arrow) also appears at prior screening (d). e, f Minimal sign screen-detected breast cancer. A 67-year-old woman presenting with a spiculated mass in the upper outer quadrant at screening (arrow), right MLO view (e), diagnosed with a 17-mm invasive lobular carcinoma. A non-specific focal asymmetry (arrow) is visible on prior screening mammograms (f)
Fig. 3
Fig. 3
Mammographic findings on prior screening mammograms of missed and minimal sign cancers, stratified by mammographic findings on mammograms at diagnosis of screen-detected breast cancer
Fig. 4
Fig. 4
a Distribution of review classification groups based on findings on prior screening mammograms (true, missed, or minimal signs) stratified by the BI-RADS density score (low: BI-RADS a + b; high: BI-RADS c + d) (p = 0.88). b Distribution of mammographic findings at diagnosis (mass, calcifications, asymmetry, or distortion) stratified by the BI-RADS density score (p < 0.001). c Distribution of mammographic findings on prior screening mammograms stratified by the BI-RADS density score p < 0.001

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