Radiological staging in breast cancer: which asymptomatic patients to image and how

Radiological staging in breast cancer: which asymptomatic patients to image and how
T Barrett, D J Bowden, D C Greenberg, C H Brown, G C Wishart and P D Britton
Br J Cancer 2009 101: 1522-1528

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The findings from this Cambridge audit, prompted new local guidelines for staging asymptomatic breast cancer patients:

Only clinical stage III or IV patients require baseline investigation

The high specificity and convenience of computed tomography (chest, abdomen and pelvis including proximal femur) led us to recommend this as the investigation of choice in breast cancer patients requiring radiological staging

One-stop diagnostic breast clinics: how often are breast cancers missed?

One-stop diagnostic breast clinics: how often are breast cancers missed?
Britton, S W Duffy, R Sinnatamby, M G Wallis, S Barter, M Gaskarth, A O'Neill, C Caldas, J D Brenton, P Forouhi & G C Wishart
British Journal of Cancer (2009) 100, 1873 – 1878

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The aim of this study was to estimate the number of patients discharged from a symptomatic breast clinic who subsequently develop breast cancer and to determine how many of these cancers had been ‘missed’ at initial assessment. Over a 3-year period, 7004 patients were discharged with a nonmalignant diagnosis. Twenty-nine patients were subsequently diagnosed with breast cancer over the next 36 months. This equates to a symptomatic ‘interval’ cancer rate of 4.1 per 1000 women in the 36 months after initial assessment (0.9 per 1000 women within 12 months, 2.6 per 1000 women within 24 months). The lowest sensitivity of initial assessment was seen in patients of 40 – 49 years of age, and these patients present the greatest imaging and diagnostic challenge.

Following multidisciplinary review, a consensus was reached on whether a cancer had been missed or not. No delay occurred in 10 patients (35%) and probably no delay in 7 patients (24%). Possible delay occurred in three patients (10%) and definite delay in diagnosis (i.e., a ‘missed’ cancer) occurred in only nine patients (31%). The overall diagnostic accuracy of ‘triple’ assessment is 99.6% and the ‘missed’ cancer rate is 1.7 per 1000 women discharged

Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome

Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome
L E M Duijm, M W J Louwman, J H Groenewoud, L V van de Poll-Franse, J Fracheboud & J W Coebergh
Br J Cancer 2009 100: 901-907

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Twenty-one screening mammography radiographers and eight screening radiologists participated. A total of 106 093 screening mammograms were double-read by two radiographers and, in turn, by two radiologists. Initially, radiologists were blinded to the referral opinion of the radiographers. A woman was referred if she was considered positive at radiologist double-reading with consensus interpretation or referred after radiologist review of positive cases at radiographer double-reading.

We conclude that screener performance significantly varied at single-reading. Double-reading increased sensitivity by a relative 7.3%. When there is a shortage of screening radiologists, triple reading by one radiologist and two radiographers may replace radiologist double-reading.