This study aimed to identify predictors of nonadherence to breast cancer screening guidelines in an urban screening clinic among high- and average-risk women in the United States.
We reviewed records of 6090 women who received ≥2 screening mammograms over 2 years at the Karmanos Cancer Institute to examine how breast cancer risk and breast density were associated with guideline-concordant screening. Incongruent screening was defined as receiving supplemental imaging between screening mammograms for average-risk women, and as not receiving recommended supplemental imaging for high-risk women. We used t-tests and chi-square tests to examine bivariate associations with guideline-congruent screening, and probit regression to regress guideline-congruence unto breast cancer risk, breast density, and their interaction, controlling for age and race.
Incongruent screening was more likely among high- versus average-risk women (97.7% vs. 0.9%, p < 0.01). Among average-risk women, incongruent screening was more likely among those with dense versus nondense breasts (2.0% vs. 0.1%, p < 0.01). Among high-risk women, incongruent screening was more likely among those with nondense versus dense breasts (99.5% vs. 95.2%, p < 0.01). The significant main effects of density and high-risk on increased incongruent screening were qualified by a density by high-risk interaction, showing a weaker association between risk and incongruent screening among women with dense breasts (simple slope = 3.71, p < 0.01) versus nondense breasts (simple slope = 5.79, p < 0.01). Age and race were not associated with incongruent screening.
Lack of adherence to evidence-based screening guidelines has led to underutilization of supplementary imaging for high-risk women and potential overutilization for women with dense breasts without other risk factors.

Canadian and US Task Forces recommend against routine mammography screening for women age 40-49 at average breast cancer risk as harms outweigh benefits. Both suggest individualized decisions based on the relative value women place on potential screening benefits and harms. Population-based data reveal variation in primary care professionals (PCPs) mammography rates in this age group after adjusting for sociodemographic factors, highlighting the need to explore PCP screening perspectives and how this informs clinical behaviours. Results from this study will inform interventions that can improve guideline concordant breast screening for this age group.
Qualitative semi-structured interviews were performed with PCPs in Ontario, Canada. Interviews were structured using the theoretical domains framework (TDF) to explore determinants of breast cancer screening best-practice behaviours: (1) risk assessment; (2) discussion regarding benefits and harms; and (3) referral for screening.
Interviews were transcribed and analyzed iteratively until saturation. Transcripts were coded deductively by behaviour and TDF domain. Data that did not fit within a TDF code were coded inductively. The research team met repeatedly to identify potential themes that influenced or were important consequences of the screening behaviours. The themes were tested against further data, disconfirming cases, and different PCP demographics.
Eighteen physicians were interviewed. The theme of perceived guideline clarity (a lack of clarity on guideline-concordant practices) influenced all behaviours and moderated the extent to which the risk assessment and discussion occurred. Many were unaware of how risk-assessment factored into the guidelines and/or did not perceive that a shared-care discussion was guideline-concordant. Deferral to patient preference (screening referral without a complete discussion of benefits and harms) occurred when the PCPs had low knowledge regarding harms and/or if they experienced regret (TDF domain: emotion) resulting from prior clinical experiences. Older providers described patient\'s influence impacting their decisions and physicians trained outside Canada, practicing in higher-resourced areas, and female physicians described being influenced by beliefs about consequences of benefits of screening.
Perceived guideline clarity is an important driver of physician behaviour. Improving guideline concordant care should start by clarifying the guideline itself. Thereafter, targeted strategies include building skills in identifying and overcoming emotional factors and communication skills important for evidence-based screening discussions.

OBJECTIVE: To support shared decision-making, patient-facing resources are needed to complement recently published guidelines on approaches for surveillance mammography in breast cancer survivors aged ≥ 75 or with < 10-year life expectancy. We created a patient guide to facilitate discussions about surveillance mammography in older breast cancer survivors.
METHODS: The \"Are Mammograms Still Right for Me?\" guide estimates future ipsilateral and contralateral breast (in-breast) cancer risks, general health, and the potential benefits/harms of mammography, with prompts for discussion. We conducted in-clinic acceptability testing of the guide by survivors and their clinicians at a National Cancer Institute-designated comprehensive cancer center, including two community practices. Patients and clinicians received the guide ahead of a clinic visit and surveyed patients (pre-/post-visit) and clinicians (post-visit). Acceptability was defined as ≥ 75% of patients and clinicians reporting that the guide (a) should be recommended to others, (b) is clear, (c) is helpful, and (d) contains a suitable amount of information. We also elicited feedback on usability and mammography intentions.
RESULTS: We enrolled 45 patients and their 21 clinicians. Among those responding in post-visit surveys, 33/37 (89%) patients and 15/16 (94%) clinicians would recommend the guide to others; 33/37 (89%) patients and 15/16 (94%) clinicians felt everything/most things were clear. All other pre-specified acceptability criteria were met. Most patients reported strong intentions for mammography (100% pre-visit, 98% post-visit).
CONCLUSIONS: Oncology clinicians and older breast cancer survivors found a guide to inform mammography decision-making acceptable and clear. A multisite clinical trial is needed to assess the guide\'s impact mammography utilization.
BACKGROUND: ClinicalTrials.gov-NCT03865654, posted March 7, 2019.

Background Intraductal papillomas (IDPs) are typically classified as B3 lesions in histology as they may show intralesional heterogeneity with a potential upgrade to malignancy. On core needle biopsy (CNB), a distinction between papilloma versus papillary ductal carcinoma in situ (DCIS) may be difficult. It is well known that otherwise benign papillomas may harbor foci of atypical ductal hyperplasia or DCIS. In this study, we aimed to calculate the radiological (mammogram and ultrasound) accuracy of IDP and to analyze the accuracy of CNB to diagnose IDP. Furthermore, we calculated the percentage of upgrade to malignancy after surgical excision. Any case that had a co-existing in-situ or invasive carcinoma during surgical excision was considered as an \"upgrade\" to malignancy. Finally, we analyzed the current management protocol for IDP in the institution and suggested changes, if needed. Methodology This is a retrospective cross-sectional study. A total of 112 cases diagnosed as IDP radiologically and/or by histopathology over a one-year time frame were included. A retrospective analysis of the accuracy of the radiological diagnosis was done by comparing it with CNB and/or surgical excision biopsy reports. The number of cases diagnosed with a co-existing in-situ or invasive carcinoma was calculated. This was considered as an \"upgrade\" from a B3 lesion in CNB to carcinoma in surgical excision. Current institutional management protocols were evaluated and compared with international benchmarks. Results Out of the 112 cases, 91 were suspected to be papilloma by imaging. The remaining 21 cases who were positive for papilloma on biopsy but were not diagnosed radiologically were also studied separately. Among the biopsied patients, eight were positive for IDP with atypia in CNB. Five out of these eight cases had an in-situ or invasive component during the surgical excision, with one invasive lobular carcinoma, three lobular carcinomas in situ, and one DCIS on surgical excision histopathology. The upgrade percentage was calculated to be 22.72%. Conclusions Due to the large upgrade potential of IDP, it is recommended to biopsy every radiologically suspected lesion and excise pathology-proved lesions. If the biopsy shows papilloma without atypia, vacuum excision is sufficient; otherwise, surgical excision with a clearance of margins is advocated. Annual mammograms/surveillance is recommended for biopsy-proven cases. IDP has a high upgrade potential, and, hence, care should be taken to biopsy suspicious lesions. An excision of biopsy-proven lesions must be done.

OBJECTIVE: To increase clinician adherence to mammography screening guidelines.
METHODS: Quality improvement initiative.
UNASSIGNED: At a nurse practitioner-led primary care practice, a chart audit of adherence to American Cancer Society mammography screening guidelines indicated a 12% adherence rate for clinicians writing mammography orders.
METHODS: Nurse practitioners providing care to women ages 40 years and older.
UNASSIGNED: The intervention was a screening checklist that was completed by the woman at registration and given to the clinician during the examination. The pre- and postintervention measurement was the percentage of mammogram orders. A Fisher exact test was used to examine changes from pre- to postintervention rates of adherence.
RESULTS: After the intervention, the percentage of women for whom a mammogram was recommended and ordered was 69.6%, compared to 12% from the original chart audit. This change was statistically significant (p = .01).
CONCLUSIONS: Clinicians must find efficient approaches to improve processes within their practice settings to ensure that preventive care recommendations are made during visits. Although the screening checklist was deemed useful, improvement in adherence rates is still needed, and a paperless system should be initiated.

Background Various guidelines exist for female preventative screening tests and medical resident physician adherence to the United States Preventive Services Task Force (USPSTF) guidelines varies. National screening rates for breast cancer and osteoporosis have improved but they are still below the expected target. Material and methods Ambulatory medical clinic records of female patients from the period July 2015 to December 2017 were reviewed for breast cancer and osteoporosis screening. Resident performance and commitment with regards to ordering the aforementioned screening tests according to the USPSTF guidelines were compared to the most recent national screening rates for mammograms and dual-energy X-ray absorptiometry (DXA) scans. Results Of the 1327 charts reviewed, 1025 was included in the study. Of the 545 mammograms performed, 93% of them were indicated according to the USPSTF guidelines (P < 0.0001, 95% CI: 125.9-342.0). A total of 480 mammograms were not ordered, of which 6% were indicated and 93.9% were not indicated. Out of a total of 107 DXA scans performed, 88.7% were correctly indicated (P < 0.0001, 95% CI: 37.11-132.9). Conclusion Resident physician adherence to the USPSTF screening guidelines for breast cancer and DXA scans were higher than the national and state screening rates. Our well-structured educational project (strong faculty mentorship, resident to patient continuity of care and the reasonable resident-clinic load) resulted in higher screening rates.

In recently updated breast cancer screening guidelines, the American Cancer Society (ACS) and United States Preventive Services Task Force (USPSTF) recommended increasing mammography screening intervals for various age groups. In addition, ACS does not recommend clinical breast examination (CBE) for routine screening among average-risk women. Our study explores women\'s attitudes regarding screening mammography and CBE and evaluates the impact of the updated USPSTF and ACS guidelines on these attitudes.
Six hundred fourteen patients presenting to Mayo Clinic, Arizona and Minnesota, in July 2016 completed a self-administered survey, which included a summary of the updated guidelines.
A majority of the 555 women who fit the inclusion criteria reported that CBE and mammogram are useful in detecting breast cancer and should be performed annually, and 51% of participants were unaware of the updated guidelines. Before reviewing the guidelines, 77% believed yearly CBE and 76% believed yearly mammogram was needed for routine screening. After reviewing the guidelines, the percentage of women who planned to continue with yearly CBE and mammogram decreased significantly to 61% and 64%, respectively (p < 0.001 and p < 0.001). Nearly half the participants (48%) believed the most influential reason for the guideline change was to decrease healthcare spending.
Breast cancer screening is well received among patients, and a majority of surveyed women were unaware of recent guideline changes. After reviewing the guidelines, there was a significant downward shift in intended screening frequency, although the majority still planned to undergo annual screening. Informing women about updated evidence-based guidelines may influence their knowledge, preferences, and opinions.

暂无摘要。

Screening with breast ultrasound in combination with mammography is needed to investigate a clinical breast mass (Grade B), colored single-pore breast nipple discharge (Grade C), or mastitis (Grade C). The BI-RADS system is recommended for describing and classifying abnormal breast imaging findings. For a breast abscess, a percutaneous biopsy is recommended in the case of a mass or persistent symptoms (Grade C). For mastalgia, when breast imaging is normal, no MRI or breast biopsy is recommended (Grade C). Percutaneous biopsy is recommended for a BI-RADS category 4-5 mass (Grade B). For persistent erythematous nipple or atypical eczema lesions, a nipple biopsy is recommended (Grade C). For distortion and asymmetry, a vacuum core-needle biopsy is recommended due to the risk of underestimation by simple core-needle biopsy (Grade C). For BI-RADS category 4-5 microcalcifications without any ultrasound signal, a minimum 11-G vacuum core-needle biopsy is recommended (Grade B). In the absence of microcalcifications on radiography cores additional samples are recommended (Grade B). For atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, flat epithelial atypia, radial scar and mucocele with atypia, surgical excision is commonly recommended (Grade C). Expectant management is feasible after multidisciplinary consensus. For these lesions, when excision margins are not clear, no new excision is recommended except for LCIS characterized as pleomorphic or with necrosis (Grade C). For grade 1 phyllodes tumor, surgical resection with clear margins is recommended. For grade 2 phyllodes tumor, 10mm margins are recommended (Grade C). For papillary breast lesions without atypia, complete disappearance of the radiological signal is recommended (Grade C). For papillary breast lesions with atypia, complete surgical excision is recommended (Grade C).

Conversely to breast cancer, few data and guidelines are available to explore and manage benign breast disorders. Therefore, the Collège national des gynécologues et obstétriciens français (CNGOF - French College of Gynaecologists and Obstetricians) decided to establish clinical practice guidelines for benign breast tumour (BBT). CNGOF appointed a committee with responsibility for selecting experts, compiling questions and summarizing the recommendations. The summary of valid scientific data for each question analyzed by the experts included a level of evidence, based on the quality of the data available and defined accordingly rating scheme developed by the Haute Autorité de santé (French National Authority for Health).