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DOI 10.1007/s00330-009-1588-y
Kevin M. Kelly
Judy Dean
W. Scott Comulada
Sung-Jae Lee
K. M. Kelly (*)
Huntington Memorial Hospital,
Huntington-Hill Breast Center,
Pasadena, CA, USA
e-mail: drkelly@ca.rr.com
Tel.: +1-626-7936141
Fax: +1-775-2561845
J. Dean
1525 State St. Suite 102,
Santa Barbara, CA, 93101, USA
e-mail: judy@judydeanmd.net
W. S. Comulada . S.-J. Lee
Semel Institute Center for Community
Health, University of California,
Los Angeles, CA, USA
e-mail: scomulad@ucla.edu
e-mail: sjlee@mednet.ucla.edu
ULTRASOU ND
Introduction
Despite progress in identifying risk factors and genetic
markers for breast cancer, approximately 7080% of cases
occur in women without known major predictors [13].
Population-based screening for early detection of breast
cancer is therefore the primary strategy for reducing breast
cancer mortality.
Mammography as the standard imaging method for
breast cancer screening [4] has resulted in reduced breast
cancer mortality. However, the number of cancers escaping
detection with mammography is substantial, particularly in
dense-breasted women, with sensitivity as low as 3048%
735
736
737
Results
Participants
All cancers
Stage
0
1
2a
2b
3a
3b
Ductal carcinoma in situ
Invasive cancer
Invasive ductal
Invasive lobular
Grade of invasive cancers
I
II
III
Size of invasive cancers
5 mm or less c
6 to 10 mm
11 to 20 mm
21 to 50 mm
over 5 cm
Number
of cancers
N
Imaged by
mammography only
n (%)
n (%)
95% CI
n (%)
57
23 (40)
(27.5,54)
15 (26)
8 (14)
11 (19)
7
33
10
3
2
2
7
50
42
8
1 (14)
17 (51.5)
4 (40)
0 (0)
1 (50)
0 (0)
1 (14)
22 (44)
18 (43)
4 (50)
(0,58)
(33.5,69)
(12,74)
(0,71)
(1,99)
(0,84)
(0,58)
(30,59)
(28,59)
(16,84)
2
10
2
1
0
0
2 (28.5)
13 (26)
12 (28.5)
1 (12.5)
4
3
0
1
1
0
4
4
3
1
0
3
4
1
1
2
0 (0)
11 (22)
9 (21)
2 (25)
15
21
13
7 (47)
13 (62)
2 (15)
(21,73)
(38,82)
(2,45)
5 (33)
5 (24)
2 (15)
1 (7)
0 (0)
3 (23)
2 (13)
3 (14)
6 (46)
3
18
20
6
3
1 (33)
13 (72)
6 (30)
1 (17)
1 (33)
(1,90.5)
(46.5,90)
(12,54)
(0,64)
(1,90.5)
1
3
8
1
0
1
2
0
1
0
0
0
6
3
2
(57)
(8)
(7)
(12.5)
Neither
(33)
(17)
(40)
(17)
(0)
(33)
(11)
(0)
(17)
(0)
(0)
(0)
(30)
(50)
(67)
738
739
Table 2 Non-palpable breast cancer detections by imaging methods and breast density
Breast density Number
Number of Imaged only
according to
of patients cancers
by AWBU
BI-RADS
N (%)
N
n (%)
95% CI
1
2
3
4
3
(fatty)
(mixed)
(dense)
(ex dense)
&4
148 (2)
1,930 (30)
3,923 (61)
424 (6.5)
4,347 (68)
2
6
42
7
49
1 (50)
2 (33)
15 (36)
5 (71)
20 (41)
Imaged by both
Imaged by
Neither
AWBU and mammography mammography only
c
(1,99)
(4,78)
(21.5,52)
(29,96)
(27,56)
n (%)
n (%)
n (%)
1 (50)
2 (33)
11 (26)
1 (14)
12 (24)
0
1
7
0
7
0 (0)
1 (17)
9 (21)
1 (14)
10 (20)
(0)
(17)
(17)
(0)
(14)
p value
1.00
0.13
0.06
0.02
Retrospective review
The only detected invasive cancer over 5 cm was a nonpalpable invasive lobular carcinoma, evident by AWBU but
not visible even in retrospect with mammography. Another
large invasive lobular cancer that occurred early in the study
was not detected prospectively by either mammography or
AWBU, but in retrospect is evident by AWBU.
Review of the interval cancers detected clinically within a
year of negative imaging showed 9 out of 11 were evident in
retrospect by AWBU, and 1 of these was also evident in
retrospect by mammography. Two interval cancers were not
evident on either mammography or AWBU.
Discussion
AWBU with mammography is significantly better than
mammography alone for detecting breast cancer, espe-
BI-RADS 0
n/N, %
BI-RADS 3
n/N, %
All mammograms b
Screening mammograms
AWBU
Both mammography and AWBU
AWBU only d
208/6425, 3.2%
208/4991, 4.2%
465/6425, 7.2%
50/6425, 0.8%
415/6425, 6.45%
39/6425,
39/4991,
77/6425,
10/6425,
67/6425,
0.6%
0.8%
1.2%
0.15%
1.0%
BI-RADS 4 or 5
n/N, %
59/6425, 0.9%
99/6425, 1.5%
24/6425, 0.4%
75/6425, 1.2%
740
Number of cancers
Number of biopsies
Percentage positive
95% CI
23
38
23
15
8
59
99
75
24
35
39.0%
38.4%
30.7%
62.5%
22.9%
26.6
28.8
20.5
40.6
10.4
to
to
to
to
to
52.6%
48.7%
42.4%
81.2%
40.1%
741
Conclusion
Limiting AWBU examinations to a high-risk group with
dense breasts, similar to the BRCA1/2 studies with MRI
[40, 41], would dramatically reduce the cost per cancer
diagnosis. In our study 87% of cancer detections added by
AWBU were found in the 68% of studies in women with
dense/very dense breasts. Further study should focus on
better defining the combination of risk factors and imaging
characteristics that warrant supplementation of mammography with AWBU.
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