Breast density is a strong additional risk factor for breast cancer, although it is unknown whether reduction in breast density would reduce risk. Our risk model may be able to identify women at high risk for breast cancer for preventive interventions or more intensive surveillance.

for the Breast Cancer Surveillance Consortium IMPORTANCE After the US Food and Drug Administration (FDA) approved computer-aided detection (CAD) for mammography in 1998, and the Centers for Medicare and Medicaid Services (CMS) provided increased payment in 2002, CAD technology disseminated rapidly. Despite sparse evidence that CAD improves accuracy of mammographic interpretations and costs over $400 million a year, CAD is currently used for most screening mammograms in the United States. OBJECTIVE To measure performance of digital screening mammography with and without CAD in US community practice. DESIGN, SETTING, AND PARTICIPANTS We compared the accuracy of digital screening mammography interpreted with (n = 495 818) vs without (n = 129 807) CAD from 2003 through 2009 in 323 973 women. Mammograms were interpreted by 271 radiologists from 66 facilities in the Breast Cancer Surveillance Consortium. Linkage with tumor registries identified 3159 breast cancers in 323 973 women within 1 year of the screening.MAIN OUTCOMES AND MEASURES Mammography performance (sensitivity, specificity, and screen-detected and interval cancers per 1000 women) was modeled using logistic regression with radiologist-specific random effects to account for correlation among examinations interpreted by the same radiologist, adjusting for patient age, race/ethnicity, time since prior mammogram, examination year, and registry. Conditional logistic regression was used to compare performance among 107 radiologists who interpreted mammograms both with and without CAD.RESULTS Screening performance was not improved with CAD on any metric assessed. Mammography sensitivity was 85.3% (95% CI, 83.6%-86.9%) with and 87.3% (95% CI, 84.5%-89.7%) without CAD. Specificity was 91.6% (95% CI, 91.0%-92.2%) with and 91.4% (95% CI, 90.6%-92.0%) without CAD. There was no difference in cancer detection rate (4.1 in 1000 women screened with and without CAD). Computer-aided detection did not improve intraradiologist performance. Sensitivity was significantly decreased for mammograms interpreted with vs without CAD in the subset of radiologists who interpreted both with and without CAD (odds ratio, 0.53; 95% CI, 0.29-0.97). CONCLUSIONS AND RELEVANCEComputer-aided detection does not improve diagnostic accuracy of mammography. These results suggest that insurers pay more for CAD with no established benefit to women.

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Objective-To evaluate the effectiveness of methods that control for confounding by indication, we compared breast cancer recurrence rates among women receiving adjuvant chemotherapy versus those who did not.Study Design and Setting-In a medical record review-based study of breast cancer treatment in older women (n=1798) diagnosed 1990-1994, our crude analysis suggested adjuvant Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusion-Conventional methods do not control for unmeasured factors, which often remain important when addressing confounding by indication. PS and IV analysis methods can be useful under specific situations, but neither method adequately controlled confounding by indication in this study. NIH Public AccessAuthor Manuscript J Clin Epidemiol. Author manuscript; available in PMC 2011 January 1.

Attention to nonadherence among older women at risk of discontinuation, particularly those receiving BCS without radiotherapy, might improve breast cancer outcomes for these women.

Community screening mammographic performance measurements of cancer outcomes for the majority of radiologists in the BCSC surpass performance recommendations. Recall rate for almost half of radiologists, however, is higher than the recommended rate.

Background Identifying risk factors for breast cancer specific to women in their forties could inform screening decisions. Purpose To determine what factors increase risk for breast cancer in women age 40–49 years and the magnitudes of risk for each factor. Data Sources MEDLINE (January 1996 to November 2011), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (fourth Quarter 2011), Scopus, and reference lists for published studies; and data from the Breast Cancer Surveillance Consortium (BCSC). Study Selection English-language studies and systematic reviews of risk factors for breast cancer in women age 40–49 years. Additional inclusion criteria were applied for each risk factor. Data Extraction Data on participants, study design, analysis, follow-up, and outcomes were abstracted. Study quality was rated using established criteria and only studies rated good or fair were included. Results were summarized using meta-analysis when sufficient studies were available, or from the best evidence based on study quality, size, and applicability when meta-analysis was not possible. BCSC data were analyzed with proportional hazards models using partly conditional Cox regression. Reference groups for comparisons were set at U.S. population means. Data Synthesis 65 studies provided data for estimates. Extremely dense breasts on mammography or first-degree relatives with breast cancer were associated with ≥2-fold increase in breast cancer. Prior breast biopsy, second degree relatives with breast cancer, or heterogeneously dense breasts were associated with 1.5–2.0 increased risk; current oral contraceptive use, nulliparity, and age ≥30 at first birth were associated with 1.0–1.5 increased risk. Limitations Studies varied by measures, reference groups, and adjustment for confounders; effects of multiple risk factors were not considered. Conclusions Extremely dense breasts and first degree relatives with breast cancer were each associated with ≥2-fold increased breast cancer risk in women age 40–49. Identification of these risk factors may be useful for personalized mammography screening. Primary Funding Source National Cancer Institute Activities to Promote Research Collaboration supplement (U01CA086076-10S1). Data collection was supported by the National Cancer Institute funded Breast Cancer Surveillance Consortium (BCSC) cooperative agreement (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, U01CA70040).

Breast density largely explained decreased mammographic sensitivity at 12 months, whereas rapid tumor growth contributed to decreased mammographic sensitivity at 24 months. A 12-month versus a 24-month mammography screening interval may therefore reduce the adverse impact of faster growing tumors on mammographic sensitivity in younger women.