Missed Breast Cancer Risk Factors and Clinicopathologic Features: A Six-Year Analysis of Data from a Single Institution

BACKGROUND: Breast cancer is the second most commonly diagnosed cancer in women, but mortality has been consistently decreasing due to the introduction of screening mammography and continual innovations in treatment [1,13,15]. However, cancers missed on screening and diagnostic imaging studies impede further reductions in mortality, necessitating scrutiny of common themes in these cases. OBJECTIVE: To investigate common characteristics of breast cancers missed on multimodality screening or diagnostic imaging at a single institution. METHODS: In an IRB-approved, HIPAA compliant retrospective study, we identified all patients who received a BI-RADS 1-3 assessment and were subsequently diagnosed with breast cancer within 1 year of their negative imaging study taken between January 1, 2014 and January 31, 2020 in our institution. We collected age, ethnicity, BI-RADS rating, time elapsed before detection, imaging modality that missed/detected the cancer, symptomatic/asymptomatic status at the time of diagnosis, presenting symptom, type, size, grade, hormone receptor positivity, lymph node positivity, Ki-67, family history of breast cancer, personal history of breast cancer, time elapsed since previous diagnosis, same/contralateral breast recurrence, mutation and treatment from patient charts. A matched cohort based on mammographic breast density was created from true positive cancers randomly selected from studies with BIRADS 4-5 designation in patients whose biopsies revealed cancer within the same time frame. For comparison, we used Pearson's chi-squared to evaluate discrete variables and unpaired student's t-test with unequal variance to evaluate continuous variables with p value significance at <0.05. RESULTS: We identified 154 false negative studies corresponding to 128 missed cancers given that cancers were missed on more than one imaging study in some patients. The comparison cohort comprised 127 breast density matched true positive cancers. Mean age (60.94 years vs. 60.99 years, p=0.97) and race [(White 76.56%, Black 12.50%, Asian 3.91%, Hispanic 6.25% and Other 0.78%) vs. (White 67.72%, Black 18.11%, Asian 5.51% and Hispanic 8.66%), p=0.43] were not significantly different between false negative and true positive groups. There was a higher rate of patients symptomatic at the time of diagnosis (59.38% vs. 46.46%, p=0.039) and a higher rate of patients with deleterious genetic mutations (18.75% vs. 6.30%, p=0.0027) in the false negative cohort. There was a significantly increased rate of prior personal history of breast cancer (40.63% vs. 18.90%, p<0.001) and family history of breast cancer (68.75% vs. 48.82%, p=0.0049) in the false negative cohort. Personal history of breast cancer (36.84% vs. 13.56%, p=0.0024) and family history of breast cancer (65.79% vs. 45.76%, p=0.020) remained statistically significant even when asymptomatic cancers, including asymptomatic MRI-detected cancers were removed. Mean tumor size was significantly smaller in the false negative cohort (21.19 mm vs. 32.38 mm, p= 0.0014). False negative studies were screening mammogram in 34.42% (53/154), screening digital breast tomosynthesis in 23.38% (36/154), diagnostic mammography in 21.43% (33/154), diagnostic digital breast tomosynthesis in 7.79% (12/154), ultrasound in 6.49% (10/154) and MRI in 6.49% (10/154). False negative cancers were detected with diagnostic mammography in 26.56% (34/128), MRI in 26.56% (34/128), ultrasound in 17.97% (23/128), diagnostic digital breast tomosynthesis in 14.06% (18/128), screening digital breast tomosynthesis in 8.59% (11/128), ultrasound guided biopsy in 1.56% (2/128), chest CT in 0.78% (1/128) and outside study in 0.78% (1/128). In the true positive cohort, cancer was detected with screening mammography in 43.31% (55/127), diagnostic mammography in 37.80% (48/127), screening digital breast tomosynthesis in 11.02% (14/127), ultrasound in 4.72% (6/127), diagnostic digital breast tomosynthesis in 1.57% (2/127) and breast MRI in 1.57% (2/127). CONCLUSION: Surveillance in breast cancer survivors follows standard recommendations of annual mammography [16,20]. These findings invite the notion that supplemental screening to detect interval cancers may be useful in breast cancer survivors.

Author dc:creator

• Franklin, Jordan Elizabeth

Contributors dc:contributor

• Dogan, Basak E.
• Hayes, Jody C.
• Knippa, Emily E.

• Breast Neoplasms
• Diagnostic Errors
• False Negative Reactions
• Magnetic Resonance Imaging
• Mammography
• Ultrasonography, Mammary

Language dc:language

en

Identifier

1522122348

OAI identifier oai:identifier

oai:utswmed-ir.tdl.org:2152.5/10618