CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.
“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self–breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.
“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self–breast exam,” Dr. Lehman said.
The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.
Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.
In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.
The rate of biopsy was high, and the yield was low. For example, of the 140 patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign), 46 (33%) underwent tissue sampling, and none of these lesions was found to be malignant.
Mammography was not indicated in this setting, and close surveillance might be a preferred alternative to tissue sampling, the authors concluded.
The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.
In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.
The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.
“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”
In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.
“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.
At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.
Scientific session moderator Dr. Ellen B. Mendelson of Northwestern University in Chicago commented: “For every patient 30 years old or older who we'd biopsy, we'd do mammography first.
“In a patient younger than that … the first imaging exam you'd do for something palpable, or that is symptomatic, would be ultrasound. Then, depending on what you find … we would go to bilateral mammography first, before biopsy,” she said.
Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.
“We don't recommend ultrasound as a screening tool,” said Dr. Constance Lehman (left), with coauthors Dr. Michael Portillo and Dr. Vilert Loving.
Source Richard Hyer/Elsevier Global Medical News