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Regarding Trends in Recall, Biopsy, and Positive Biopsy Rates for Screening Mammography

Norma J. Vinger Center for Breast Care, Gundersen Lutheran Medical Center EB1-002,
1900 South Avenue, La Crosse, WI 54601
e-mail: rlellis{at}gundluth.org

Editor:

I read with interest the article by Dr Gur and colleagues, entitled "Trends in Recall, Biopsy, and Positive Biopsy Rates for Screening Mammography in an Academic Practice" (1), in the May 2005 issue of Radiology. The authors should be applauded for their efforts and willingness to share their performance data for recall, biopsy, and positive biopsy rates for screening mammography, as well as the number of cancers detected for each quarter (nine consecutive calendar quarters). However, I could not help but wonder why the authors did not include the mean and median size of the invasive cancers detected with screening mammography. The mean and median tumor size for invasive cancers detected with screening should be considered the first order of business when trying to determine if a radiology group and/or its individual members are having an impact on morbidity and mortality from breast cancer (2–6).

The primary purpose of screening mammography is to reduce mortality from breast cancer. Prognostic indicators for breast cancer survival include tumor size, tumor type, tumor grade, mammographic presentation, regional lymph node status, and metastatic disease. However, tumor size is recognized as acting as a governor that directly influences the other prognostic indicators. It is critical to understand that invasive breast carcinoma must be detected at an early phase of its natural history, allowing the disease to be interrupted prior to the development of regional or systemic metastatic disease, in order to have the greatest effect on reducing breast cancer mortality. Provided with this information, it would be of much interest if Dr Gur and colleagues would share the mean and median size of the invasive cancers detected with screening mammography from their recent report.

References

1. Gur D, Wallace LP, Klym AH, et al. Trends in recall, biopsy, and positive biopsy rates for screening mammography in an academic practice. Radiology 2005;235(2):396–401.[Abstract/Free Full Text]
2. Michaelson JS, Satija S, Kopans D, et al. Gauging the impact of breast carcinoma screening in terms of tumor size and death rate. Cancer 2003;98(10):2114–2124.[CrossRef][Medline]
3. Michaelson JS, Silverstein M, Wyatt J, et al. Predicting the survival of patients with breast carcinoma using tumor size. Cancer 2002;95(4):713–723.[CrossRef][Medline]
4. Tabar L, Duffy SW, Vitak B, Chen HH, Prevost TC. The natural history of breast carcinoma: what have we learned from screening? Cancer 1999;86(3):449–462.[CrossRef][Medline]
5. Tabar L, Vitak B, Chen HH, Yen MF, Duffy SW, Smith RA. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast carcinoma mortality. Cancer 2001;91(9):1724–1731.[CrossRef][Medline]
6. Leung JW. Screening mammography reduces morbidity of breast cancer treatment. AJR Am J Roentgenol 2005;184(5):1508–1509.[Abstract/Free Full Text]

Dr Gur and colleagues respond:

Department of Radiology, University of Pittsburgh,
300 Halket Street, Suite 4200,
Pittsburgh, PA 15213–3180
e-mail: gurd@upmc.edu

We thank Dr Ellis for his comments. We agree that tumor size is an important parameter that correlates with ultimate prognosis, and on average, the "earlier" (and the "smaller") at detection the better the expected outcome. However, this was not the purpose of our study. Our study was not designed to address efficacy of screening in terms of possible morbidity or mortality, and the time frame of our study does not allow for such an experimental assessment for several years to come. Rather our study was designed to review possible trends, if any, related to operational variables, each having a well-defined binary outcome associated with it—namely, a decision to recall (or not), a decision to biopsy (or not), and the outcome of these biopsies in terms of being positive for cancer (or not). These data allowed us to analyze simple operational trends and summarize their impact in terms of "attributable detection." Since cancer detection rates remained substantially unchanged despite an increasing trend in the number of biopsies performed (in particular those related to microcalcification clusters), we expect to have very low statistical power to detect small changes, if any, in average tumor size of the invasive component of cancers in this limited study. In addition, we caution that one-dimensional tumor size measurements may not be as precise as one would hope for this purpose. As important perhaps, a one-dimensional measure of "size" is not likely to be the optimal measurement, nor the most sensitive one, to assess trends or as a predictive measure of outcome. With that being said, for those who underwent stereotactic vacuum-assisted core biopsies and/or US-guided core biopsies followed by surgical removal of the tumor, the average reported tumor "size" ("largest one dimension of the invasive component") as provided in pathology reports was 12.0 mm (median, 11.0 mm; range, 1.0–40.0 mm), and no significant trend was observed during the period in question.

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