| Objective:This paper includes two parts. In part I, we aim to report the feasibility of breast cancer screening in Chinese women who live in the city with high-incidence of breast cancer. In this part, we also try to explore the suitable breast cancer screening model in Chinese women and to compare performance of mammography and mammography added ultrasound in detecting breast cancer during breast cancer screening. In part?, our purpose is to investigate the second breast cancer (SBC) incidence and its clinical characteristics in women with personal breast cancer history. Another purpose in this part is to determine the performance of MRI (magnetic resonance imaging) in detecting SBC among these women.Materials and methods:the data of part I was based on a breast cancer screening program implementing in Qi Bao town which was located at Shanghai. This program started in May 2008, the first round screening ended in October 2010. Women aged 35 to 74 years who were permanent residents in this town were invited to register for this program. The eligible woman number was 13183. These women were asked to fill in questionnaires which included age, height, weight, personal history, family history and so on. After that, the women were offered breast clinical examination by community physicians. The following women were selected as intensive screening group:women aged 45 to 69 years old, those had breast cancer high risk factors and those had positive findings with breast clinical examination. There were 8234 women who fell in the intensive screening group. The women in intensive screening group were offered mammography and ultrasound screening modality. Imaging findings were classified according to ACR BI-RADS (American College Radiology Breast Imaging Reporting and Database System) lexicon. If imaging findings were suspicious of malignancy, further examination was recommended, including biopsy. The outcome of the diagnostic evaluation and subsequent treatment and pathology were recorded, analyzed, and compared with international standards. The screening performance of mammography and mammography added ultrasound was compared. The ability of mammography and ultrasound in detecting different types of breast cancer (invasive ductal carcinoma or ductal carcinoma in situ) also was compared.In part?, the participants were women with prior breast cancer who were recommended breast MRI screening between January 2007 and August 2010. In these women, we excluded those whose interval time between time of lumpectomy or mastectomy and undergoing MRI examination was less than 6 moths and who had distant metastasis during follow up. At last,798 women were eligible for the study. For the 798 women,471 women received breast conserving treatment (BCT), other 327 women underwent mastectomy. The radiology reports and electronic records of each case was reviewed and followed to ascertain if she developed SBC, including the second contralateral breast cancer (SCBC) and the second ipsilateral breast cancer (SIBC). The follow-up lasted to February 2011. On the basis of the 798 women, we calculated the incidence of SBC in women with personal breast cancer history, we also calculated the incidence of SCBC and SIBC. The incidence of SIBC was based on 471 women who received BCT. To determine the correlation between age and SBC, the patients were classified as?45 vs>45 years and?50 vs>50 years to evaluate the incidence in different groups. BI-RADS category results of each patient were noted, BI-RADS 4 or 5 was regarded as positive diagnosis, BI-RADS 3 or below was regarded as negative diagnosis. The ability of MRI detecting SBC was evaluated by comparing the BI-RADS category results with pathology findings. For the patients with SBC who were identified by MRI, if they had matching mammography or ultrasound, the ability of MRI was compared with mammography or ultrasound in detecting SBC. To calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), we took the patients who underwent MRI examination before February 2010 as research objects. Among these patients, we only selected patients who had follow-up records more than 1year or had biopsy results for MRI findings after undergoing MRI examination as study population. This subpopulation included 425 patients. The performance of MRI, mammography and ultrasound in identifying SBC also was compared by selecting 348 of the 798 patients who had MRI, mammography and ultrasound and the time interval between any two kinds of examination was not longer than 6 months. For those patients who received excisional surgery, all 3 examinations underwent before operation.Resulsts:In the program of community screening, for 8234 women who were eligible for intensive screening,8231 women completed mammography examination and 39 patients were diagnosed as breast cancer.Thirty-six of the 39 breast cancers were detected by screening and 3 of the 39 breast cancers were interval breast cancers. The incidence of breast cancer detected by screen was 273.1 per hundred thousand (36/13183). The overall rate of detection was 92.3% (36/39). Sixteen of 36 breast cancers which were detected by screening belonged to early stage, leading to a rate of early stage 41.0%(16/39). The sensitivity of mammography was 84.6%(33/39) and the sensitivity of ultrasound was 59.0%(23/39). The sensitivity of mammography was significantly higher than that of ultrasound (p=0.012). Comparing the sensitivity of mammography alone (84.6%) with that of mammography added ultrasound (92.3%) showed no statistically different (p=0.45). Average size of invasive breast cancer detected by mammography alone was 2.4cm and that of mammography added ultrasound was 2.3cm, there was no statistical difference between two sizes. The patients were stratified in?50 vs>50 years to compare the sensitivity of mammography or mammography added ultrasound in different groups. The sensitivity of mammography in older group was slightly higher than that in younger group, but the difference was not significant (p=1.00). Comparing with ultrasound, the superiority of mammography in identifying ductal carcinoma in situ was much higher than in invasive ductal carcinoma (80% vs 20.6%), the difference was significant (p=0.017). Mammography diagnosed 4 of all 5 DCISs, but none of 5 DCIS was diagnosed by ultrasound. In the first round screening,262 patients were recalled for further examination, leading to a recall rate of 3.2% (262/8234). There were 160 biopsies altogether, leading to a biopsy rate of 1.9%(160/8234). The PPV of biopsy was 22.5% (36/160).For the 798 women with personal history of breast cancer, SBC was diagnosed in 49 patients,39 of which were SCBC and 13 of which were SIBC. The overall incidence of the second breast cancer was 6.1% (49/798), the incidence of SCBC was 4.5% (36/798) and SIBC was 2.8%(13/471). The incidence of SBC in patients whose postoperative time was>36 months was much higher (13.1%) than in patients whose postoperative time was?36 months (4.1%) (p?0.0001). The incidence of SCBC in older women (>45 or>50 years old) was significantly higher than the incidence in younger women (?45 or?50 years old) (5.8%vs 2.6% or 7.1% vs 2.6%, p=0.033 or p=0.0025). If the age was adjusted to time when the primary breast cancer was diagnosed, the incidence of SCBC in older patients and younger patients showed no different (4.5% vs 3.5% or 4.8% vs 4.4%, p=0.45 or p=0.82).MRI identified 45 of the 49 second breast cancers, leading to a detecting rate of 92.8%(45/49). For the 45 cases of patients identified by MRI,36 had matching mammography and 39 had matching ultrasound examinations. However,20 cases were not identified by mammography and 12 were not identified by ultrasound. Mammography missed 55.6%(20/36) and ultrasound missed 41.0%(12/39) of lesions, respectively. On the basis of MRI findings,76 patients were classified as BI-RADS 4 or 5 and the PPV of MRI was 59.2% (45/76). The biopsies being based on MRI findings were 62, leading to a biopsy rate of 7.8% (62/798) and a PPV of biopsy of 72.6%(45/62).On the basis of 425 in follow-up group, the performance of MRI in diagnosing SBC as well as SCBC and SIBC was evaluated. The sensitivity, specificity, PPV and NPV of MRI in detecting SBC were 90.0% (36/40),94.8%(365/385),64.3% (36/56), 98.9%(365/369); those in detecting SCBC were 90.6% (29/32),97.5% (383/393), 74.3% (29/39),99.2% (383/386); those in detecting SIBC were 87.5%(7/8),97.5% (233/239),58.3% (7/12),99.6% (233/234), respectively.The performance of MRI, mammography and ultrasound in identifying SBC was compared taking advantage of 348 patients receiving 3 kinds of examination at the same time. The sensitivity, specificity, PPV and NPV of MRI in detecting SBC were 90.3%(21/23),97.5%(317/325),72.4%(21/29),99.4%(317/319); (172/173); those of mammography were 43.4%(10/23),95.4%(310/325),40%(10/25),96.0% (310/323); those of ultrasound were 73.9%(17/23),97.8%(318/325),70.8%(17/24), 98.1%(318/324), respectively.The sensitivity increased from 80.6%(25/31) to 93.5% (29/31) if adding MRI to routine examination (mammography combining ultrasound). In contrast group, there were 17 lesions which sizes were available. Routine examination diagnosed 15 of the 17 lesions. Among the 15 lesions,46.7% (7/15)<lcm and 20% (3/15)>2cm; routine examination adding MRI diagnosed 17 lesions,47.1% (7/15)<lcm and 17.6%(3/15) >2cm. The size constitute in two groups showed no difference (p=0.73).The performance of these 3 modalities in detecting SCBC as well as SIBC also showed that MRI was better than mammography or ultrasound, ultrasound was superior to mammography.Conclusions:1. Breast cancer screening on the basis of community in Chinese women were feasible. Detecting rate of breast cancer was higher and the percentage of early stage breast cancer was also higher. These will probably change prognosis of these breast cancer patients; 2. The screening model which combined breast clinical examination as initial screening for all registering women and intensive imaging screening was offered to those women who were breast cancer high risk population were effective; 3. Adding ultrasound in mammography screening may increase the detecting rate of breast cancer, but the value of ultrasound in breast cancer screening need further study. Comparing with ultrasound, superiority of mammography in diagnosing DCIS was higher than diagnosing invasive cancer.4. The incidence of SBC in women with personal history of breast cancer was much higher than common women, they were high risk women of breast cancer; 5. The performance of MRI in detecting SBC was excellent and was superior to mammography and ultrasound. MRI could detect SCBCs or SIBCs which were not detected by mammography or ultrasound. The specificity of MRI in detecting SBC was also acceptable. MRI could increase radiologists' confidence in diagnosing SBC. Comparing with routine examination, the tumors detected after adding MRI had no diffence in size. |
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