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Screening Mammography

Clinical Image Quality and the Risk of Interval Breast Cancer

¹ Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Ste. 1600, Seattle, WA 98101.
² Department of Family Medicine, University of Washington, 1935 N.E. Pacific, Seattle, WA 98195.
³ Division of Mammography, Quality, and Radiation Programs, United States Food and Drug Administration, 1350 Picard Dr., 2nd Floor-HFZ240, Rockville, MD 20850.
⁴ Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center, MP 702, 1124 Columbia St., Seattle, WA 98104.
⁵ Office of Drug Evaluation III, Center for Drug Evaluation and Research, United States Food and Drug Administration, 5600 Fishers Ln., Rockville, MD 20857.

OBJECTIVE. We evaluated the association between clinical image quality and breast cancer occurrence within 24 months of a negative mammogram.

MATERIALS AND METHODS. We identified women with breast cancer who were younger than 40 years old and older and screened from January 1, 1988, through December 31, 1993. We retrospectively assigned Breast Imaging Reporting and Data System (BI-RADS) assessments to their screening mammogram. We classified cancers (invasive or ductal in situ) as "screen-detected" when found after positive assessments (BI-RADS codes 3, 4, and 5) and "interval-detected" when found after negative assessments (BI-RADS codes 1 and 2). One reviewer evaluated mediolateral oblique and craniocaudal views for all cancer cases using a 3-point scale (failure, borderline, pass) for each measure of clinical image quality (positioning, breast compression, contrast, exposure, noise, sharpness, artifacts, overall quality). We used separate logistic regression models and evaluated the odds of interval invasive cancer or invasive plus in situ cancer as a function of each measure of quality using "pass" as the referent group.

RESULTS. We found 492 screen-detected and 164 interval-detected cancers that met study criteria. Cancer detection (sensitivity) was highest (84%) among patients with proper breast positioning, but when images failed this measure (33.4%), sensitivity fell to 66.3%. After adjustment for age, film date, and breast density, interval-detected invasive cancers were more likely after images failing positioning (odds ratio, 2.57; 95% confidence interval, 1.28-5.52%). Failures in overall quality were also associated with interval cancers when cases of ductal carcinoma in situ (p = 0.037) were included.

CONCLUSION. Invasive breast cancer detection by mammography may be improved through attention to correct positioning.

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