Faculty Bibliography

PURPOSE: Anxiety has been called a "harm" of screening mammography. The authors provided direct, interactive education to lay audiences and measured these sessions' impact on anxiety and any increased understanding of breast cancer screening. METHODS: Academic breast radiologist provided seven 1-hour sessions of structured lectures and question-and-answer periods. Lay language and radiologic images were used to discuss disease background, screening guidelines, and areas of debate. One hundred seventeen participants (mean age, 45 +/- 15 years) completed voluntary, anonymous, institutional review board-approved pre and postsession questionnaires relaying their attitudes regarding screening and the impact of the sessions. Results are summarized descriptively. RESULTS: Mean reported anxiety regarding screening (on a scale ranging from 1-5; 1 = no anxiety) was 2.5 +/- 1.3. Anxiety was attributed to unknown results (56.4%), anticipation of pain (21.8%), known risk factors (14.5%), general uncertainty (12.7%), waiting for results (9.1%), possibility of more procedures (3.6%), and personal breast cancer history (3.6%). Ninety-seven percent reported that immediate results would lower anxiety (78% of those women indicated a 75%-100% decrease in anxiety); 93% reported that radiologist consultation with images would lower anxiety (75.6% indicated a 75%-100% decrease in anxiety). After the lecture, women reported (on a scale ranging from 1-5) increased understanding of the topic (4.7 +/- 0.6), encouragement to screen (4.6 +/- 0.7), and reduced anxiety (4.0 +/- 1.1). Ninety-seven percent to 100% provided correct responses to these questions: rationale for screening in the absence of family history, recall does not equate to cancer diagnosis, benefit of prior films, and continued importance of physical examination. CONCLUSION: Attendees of radiologist-provided direct public lectures reported decreased anxiety and improved knowledge regarding screening mammography. The resultant reduced anxiety ("harm") and educational empowerment help enable informed decision making and may promote screening attendance.

OBJECTIVE: Our aim was to determine the screening recommendations that breast radiologists promote to average-risk patients and family or friends and do or would follow for themselves. MATERIALS AND METHODS: A survey of breast radiologists in the United States collected data regarding their personal and practice backgrounds, their recommendations to others for mammography and clinical and self-breast examination, and their personal screening habits based on respondent sex. The radiologists were divided into three cohorts: women 40 years old or older (group 1), women younger than 40 years (group 2), and men (group 3). The distribution of responses for each question was summarized, and proportions of total radiologists and cohorts were computed. RESULTS: Four hundred eighty-seven surveys were collected. None of the radiologists recommended biennial mammography for patients ages 50-74 years, 98% (477/487) recommended yearly mammography for patients 40 years old and older, and 99% (470/476) recommended yearly mammography for family and friends 40 years old and older. The most common reasons for variance were institutional policy or provider preferences. In group 1, 96% (191/198) have yearly mammography. In group 2, 100% (83/83) have or will have yearly mammography at age 40 years and beyond. In group 3, 97% (171/176) would have yearly mammography at age 40 years and beyond if they were women. Overall, 97% (445/457) of radiologists have or would have yearly mammography at age 40 years and beyond. CONCLUSION: Nearly all (98%) of the radiologists recommend yearly mammography for average-risk women 40 years old and older and were consistent in that they "practice what they preach." Because radiologists diagnose all stages of breast cancer, their personal convictions should influence providers, patients, and the public when considering the U.S. Preventive Services Task Force screening guidelines.

Deep neural networks (DNNs) show promise in image-based medical diagnosis, but cannot be fully trusted since they can fail for reasons unrelated to underlying pathology. Humans are less likely to make such superficial mistakes, since they use features that are grounded on medical science. It is therefore important to know whether DNNs use different features than humans. Towards this end, we propose a framework for comparing human and machine perception in medical diagnosis. We frame the comparison in terms of perturbation robustness, and mitigate Simpson's paradox by performing a subgroup analysis. The framework is demonstrated with a case study in breast cancer screening, where we separately analyze microcalcifications and soft tissue lesions. While it is inconclusive whether humans and DNNs use different features to detect microcalcifications, we find that for soft tissue lesions, DNNs rely on high frequency components ignored by radiologists. Moreover, these features are located outside of the region of the images found most suspicious by radiologists. This difference between humans and machines was only visible through subgroup analysis, which highlights the importance of incorporating medical domain knowledge into the comparison.

Launching an academic career in breast imaging presents both challenges and opportunities for the newly graduated trainee. A strategic plan aligned with one's personal strengths and interests facilitates career success and professional satisfaction. Academic departments offer multiple tracks to accommodate diverse faculty goals. The specific requirements of various tracks vary across institutions. The clinician-educator track typically encourages a focus on medical education and educational scholarship. The clinician-investigator or clinician-scholar track supports original research and grant-funded clinical trials. Finally, the clinical and clinician-administrator tracks allow for emphasis on clinical program development and leadership. As definitions of scholarship broaden, many opportunities are accessible to demonstrate excellence in the traditional areas of clinical practice, education, and research, as well as the broader fields of leadership and administration. Departmental and national society resources that advance knowledge in one's chosen area of interest are available and should be explored. Mentorship and sponsorship can provide valuable insight into identifying such resources and devising a plan for sustainable career success and work-life integration.

The management of intraductal papilloma (IDP) diagnosed on core needle biopsy (CNB) is controversial due to the variable upgrade rates to breast carcinoma (BC) on subsequent surgical excision reported in the literature. The purpose of our study was to investigate the upgrade rate of IDP diagnosed on CNB to BC in subsequent surgical excision and the impact of clinical, pathologic and radiologic variables. This is a retrospective cohort of all women who had a diagnosis of IDP on a CNB between 2005 and 2018 in a tertiary academic center with subsequent surgical excision. Upgrade was defined as ductal carcinoma in situ (DCIS) and invasive carcinoma on surgical excision. Statistical analyses included Pearson's chi-square, Wilcoxon rank-sum and logistic regression. A total of 216 women with IDP in a CNB were included. Nineteen patients (8.8%) upgraded to BC in the overall cohort, including 14 DCIS and 5 invasive carcinomas. An upgrade rate of 27% was found in atypical IDP (14 of 51 cases), while only 3% of pure IDP upgraded to BC (5 of 165 cases). Older age (>53 years) at time of biopsy (OR=1.05, 95%CI 1.01-1.09, p=0.027) and concomitant atypical ductal hyperplasia (ADH) (OR=9.69, 95%CI 3.37-27.81, p<0.0001) were significantly associated with upgrade. Our results support surgical excision of IDP on CNB when associated with ADH or diagnosed in women older than 53 years of age. The low surgical upgrade rate of 3% for pure IDP on CNB in younger women should be part of the management discussion.

We present a deep convolutional neural network for breast cancer screening exam classification, trained and evaluated on over 200,000 exams (over 1,000,000 images). Our network achieves an AUC of 0.895 in predicting the presence of cancer in the breast, when tested on the screening population. We attribute the high accuracy to a few technical advances. (i) Our network's novel two-stage architecture and training procedure, which allows us to use a high-capacity patch-level network to learn from pixel-level labels alongside a network learning from macroscopic breast-level labels. (ii) A custom ResNet-based network used as a building block of our model, whose balance of depth and width is optimized for high-resolution medical images. (iii) Pretraining the network on screening BI-RADS classification, a related task with more noisy labels. (iv) Combining multiple input views in an optimal way among a number of possible choices. To validate our model, we conducted a reader study with 14 readers, each reading 720 screening mammogram exams, and show that our model is as accurate as experienced radiologists when presented with the same data. We also show that a hybrid model, averaging the probability of malignancy predicted by a radiologist with a prediction of our neural network, is more accurate than either of the two separately. To further understand our results, we conduct a thorough analysis of our network's performance on different subpopulations of the screening population, the model's design, training procedure, errors, and properties of its internal representations. Our best models are publicly available at https://github.com/nyukat/breastcancerclassifier.

BACKGROUND:Mammographic breast density (MBD) is an independent risk factor for breast cancer. Information regarding the relationship of MBD and breast cancer biology in women with ductal carcinoma in situ (DCIS) is currently lacking. This study aimed to examine the clinicopathologic characteristics of DCIS in women stratified by MBD. METHODS:A retrospective review was performed to identify women with pure DCIS who underwent preoperative mammography between 2010 and 2018. Clinicopathologic and demographic data were collected. For the purpose of analysis, MBD was categorized as "non-dense" (Breast Imaging-Reporting and Data System [BI-RADS] density categories A and B) or "dense" (BI-RADS C and D) according to its identification in radiology reports. RESULTS:Of 3227 patients with a breast cancer diagnosis enrolled in the institutional Breast Cancer Database during the study period, 658 (20%) had pure DCIS. Of these 658 patients, 42% had non-dense breasts, and 58% had dense breasts. Most lesions were non-palpable (92%) and detected by mammography (84%). Patients with dense breasts were more likely to be younger at the time of diagnosis (p < 0.001), premenopausal (p < 0.001), and Asian (p = 0.018), and to have higher-grade disease (p = 0.006; Table 2). Family history, BRCA status, parity, mammogram frequency, palpability, method of presentation, lesion size, hormone receptor status, comedo histology, and recurrence did not differ significantly between the two groups (Table 1). The median follow-up period was 7.1 years. CONCLUSION/CONCLUSIONS:Women with pure DCIS and higher MBD are more likely to be younger at the time of diagnosis, premenopausal, and Asian, and to present with higher-grade disease. Further research on the relationship of age, MBD, and tumor biology in DCIS is warranted.

BACKGROUND:Oncologic outcomes with nipple-sparing mastectomy (NSM) continue to be established. We examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance (TND), in therapeutic NSMs. METHODS:Demographics, outcomes, and overall trends for all NSMs undertaken for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including TND. RESULTS:A total of 496 therapeutic NSMs were performed with average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4%) and ductal carcinoma in situ (50.4%). Sentinel lymph node sampling was performed in 79.8% of NSMs; 4.1% had positive frozen sentinel lymph node biopsies while 15.7% had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5%) followed by Stage 0 (31.3%).Per NSM, the rate of local recurrence was 1.6% (N=8); the rate of regional recurrence was 0.6% (N=3). In all, 171 NSMs had magnetic resonance imaging available to assess tumor-to-nipple distance (TND). NSMs with TND ≤1 centimeter (25.0% versus 2.4%, p=0.0031/p=0.1129) and ≤2 centimeters (8.7% versus 2.0%; p=0.0218/p=0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, TND ≤1 centimeter was the only significant risk factor for recurrence (OR=13.5833, p=0.0385). No factors were significant in regression analysis. CONCLUSIONS:In this group of early stage and in situ breast carcinoma, therapeutic NSM appears oncologically safe with a locoregional recurrence rate of 2.0%. Tumor-to-nipple distances of ≤1 centimeter and ≤2 centimeters trended to higher rates of recurrence.