Relative Timing of Mammography and MRI for Breast Cancer Screening: Impact on Performance Evaluation

Janie M Lee; Laura E Ichikawa; Karla Kerlikowske; Diana S M Buist; Christoph I Lee; Brian L Sprague; Louise M Henderson; Tracy Onega; Karen J Wernli; Kathryn P Lowry; Natasha K Stout; Anna N A Tosteson; Diana L Miglioretti

doi:10.1016/j.jacr.2024.06.020

Relative Timing of Mammography and MRI for Breast Cancer Screening: Impact on Performance Evaluation

J Am Coll Radiol. 2024 Nov;21(11):1722-1732. doi: 10.1016/j.jacr.2024.06.020. Epub 2024 Jul 3.

Authors

Affiliations

¹ Section Chief of Breast Imaging, Department of Radiology, University of Washington School of Medicine, Seattle, Washington; Director of Breast Imaging, Fred Hutchinson Cancer Center, Seattle, Washington. Electronic address: jmlee58@uw.edu.
² Kaiser Permanente Washington Health Research Institute, Seattle, Washington.
³ General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, San Francisco, California; Women's Health Comprehensive Clinic, San Francisco Veterans Affairs Health Care System, San Francisco, California; Director of the San Francisco Mammography Registry and Co-Director at the Veteran's Administration Advanced Fellowship in Women's Health San Francisco; Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.
⁴ Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.
⁵ Director of the Northwest Screening and Cancer Outcomes Research Enterprise, Department of Radiology, University of Washington School of Medicine, Seattle, Washington; Deputy Editor of JACR; Fred Hutchinson Cancer Center, Seattle, Washington.
⁶ University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, Vermont; Director of the Vermont Breast Cancer Surveillance System; University of Vermont Cancer Center Cancer Population Science (CPS) Program Co-Leader.
⁷ Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina; Director of the Carolina Mammography Registry and Co-Leader of UNC Lineberger Cancer Epidemiology Research Program.
⁸ Senior Director of Population Sciences, Department of Population Health Sciences, and the Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
⁹ Senior Scientific Investigator, Kaiser Permanente Washington Health Research Institute, Seattle, Washington.
¹⁰ Fred Hutchinson Cancer Center, Seattle, Washington; Associate Director of the Northwest Screening and Cancer Outcomes Research Enterprise, Department of Radiology, University of Washington School of Medicine, Seattle, Washington.
¹¹ Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts; During the study period: Associate Professor, Population Medicine, Harvard Medical School.
¹² Director of the Comparative Effectiveness Research Program, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Associate Director for Population Sciences, Dartmouth Cancer Center; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
¹³ Professor and Division Chief of Biostatistics, Biostatistics and Population Sciences and Health Disparities Program, University of California, Davis, Comprehensive Cancer Center, Davis, California.

PMID: 38969253
DOI: 10.1016/j.jacr.2024.06.020

Abstract

Objective: Mammography and MRI screening typically occur in combination or in alternating sequence. We compared multimodality screening performance accounting for the relative timing of mammography and MRI and overlapping follow-up periods.

Methods: We identified 8,260 screening mammograms performed 2005 to 2017 in the Breast Cancer Surveillance Consortium, paired with screening MRIs within ±90 days (combined screening) or 91 to 270 days (alternating screening). Performance for combined screening (cancer detection rate [CDR] per 1,000 examinations and sensitivity) was calculated with 1-year follow-up for each modality, and with a single follow-up period treating the two tests as a single test. Alternating screening performance was calculated with 1-year follow-up for each modality and also with follow-up ending at the next screen if within 1 year (truncated follow-up).

Results: For 3,810 combined screening pairs, CDR per 1,000 screens was 6.8 (95% confidence interval [CI]: 4.6-10.0) for mammography and 12.3 (95% CI: 9.3-16.4) for MRI as separate tests compared with 13.1 (95% CI: 10.0-17.3) as a single combined test. Sensitivity of each test was 48.1% (35.0%-61.5%) for mammography and 79.7% (95% CI: 67.7%-88.0%) for MRI compared with 96.2% (95% CI: 85.9%-99.0%) for combined screening. For 4,450 alternating screening pairs, mammography CDR per 1,000 screens changed from 3.6 (95% CI: 2.2-5.9) to zero with truncated follow-up; sensitivity was incalculable (denominator = 0). MRI CDR per 1,000 screens changed from 12.1 (95% CI 9.3-15.8) to 11.7 (95% CI: 8.9-15.3) with truncated follow-up; sensitivity changed from 75.0% (95% CI 63.8%-83.6%) to 86.7% (95% CI 75.5%-93.2%).

Discussion: Updating auditing approaches to account for combined and alternating screening sequencing and to address outcome attribution issues arising from overlapping follow-up periods can improve the accuracy of multimodality screening performance evaluation.

Keywords: Breast cancer screening; breast MRI; mammography; screening audit; supplemental screening.

MeSH terms

Adult
Aged
Breast Neoplasms* / diagnostic imaging
Early Detection of Cancer*
Female
Humans
Magnetic Resonance Imaging* / methods
Mammography*
Mass Screening
Middle Aged
Sensitivity and Specificity*
Time Factors
United States

Grants and funding

P01 CA154292/CA/NCI NIH HHS/United States