Rationale and Objectives
As breast magnetic resonance imaging (MRI) use grows, benchmark performance parameters are needed for auditing and quality assurance purposes. We describe the variation in breast MRI abnormal interpretation rates (AIRs) by clinical indication among a large sample of US community practices.
Materials and Methods
We analyzed data from 41 facilities across five Breast Cancer Surveillance Consortium imaging registries. Each registry obtained institutional review board approval for this Health Insurance Portability and Accountability Act compliant analysis. We included 11,654 breast MRI examinations conducted in 2005–2010 among women aged 18–79 years. We categorized clinical indications as 1) screening, 2) extent of disease, 3) diagnostic (eg, breast symptoms), and 4) other (eg, short-interval follow-up). We characterized assessments as positive (ie, Breast Imaging Reporting and Data System [BI-RADS] 0, 4, and 5) or negative (ie, BI-RADS 1, 2, and 6) and provide results with BI-RADS 3 categorized as positive and negative. We tested for differences in AIRs across clinical indications both unadjusted and adjusted for patient characteristics and registry and assessed for changes in AIRs by year within each clinical indication.
Results
When categorizing BI-RADS 3 as positive, AIRs were 21.0% (95% confidence interval [CI], 19.8–22.3) for screening, 31.7% (95% CI, 29.6–33.8) for extent of disease, 29.7% (95% CI, 28.3–31.1) for diagnostic, and 27.4% (95% CI, 25.0–29.8) for other indications ( P < .0001). When categorizing BI-RADS 3 as negative, AIRs were 10.5% (95% CI, 9.5–11.4) for screening, 21.8% (95% CI, 19.9–23.6) for extent of disease, 17.7% (95% CI, 16.5–18.8) for diagnostic, and 13.3% (95% CI, 11.6–15.2) for other indications ( P < .0001). The significant differences in AIRs by indication persisted even after adjusting for patient characteristics and registry ( P < .0001). In addition, for most indications, there were no significant changes in AIRs over time.
Conclusions
Breast MRI AIRs differ significantly by clinical indication. Practices should stratify breast MRI examinations by indication for quality assurance and auditing purposes.
Breast magnetic resonance imaging (MRI) is the most sensitive modality for detecting breast cancer, often identifying malignancy otherwise occult by mammography, ultrasound, and clinical breast examination . As the technology improves and the interpretation and reporting by radiologists become standardized, breast MRI is used for an increasing number of purposes, including high-risk screening, evaluation of extent of malignancy, evaluation of patients with metastatic axillary adenopathy and unknown primary cancer, and surveillance after cancer treatment . Moreover, the technology has now become readily available in community settings throughout the United States with interpretation and reporting completed by both subspecialty-trained breast imagers and general radiologists .
To facilitate consistent reporting of and management recommendations for breast MRI findings, the American College of Radiology published the first edition of the Breast Imaging Reporting and Data System (BI-RADS) MRI lexicon in 2003, with the most recently revised edition published in 2013 . Similar to the previously established BI-RADS mammography lexicon, the breast MRI lexicon provides common terminology for describing MRI findings. Standardized use of the lexicon and BI-RADS assessment categories allows for improved communication among radiologists and clinicians with regards to suspicious imaging findings and clinical recommendations . Recent studies have shown that the MRI BI-RADS assessment categories can accurately predict the risk of malignancy .
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Materials and methods
Data Source
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Study Population
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Clinical Indication Categorization
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BI-RADS Assessment Categorization
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Statistical Analysis
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Results
Population Characteristics
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Table 1
Study Population Characteristics by Breast MRI Clinical Indication
Patient Characteristic Screening, n (%) Extent of Disease, n (%) Diagnostic, n (%) Other, n (%) Total, n (%)P Value_N_ 3989 1954 4300 1411 11,654 Age, years <40 494 (12.4) 172 (8.8) 426 (9.9) 163 (11.6) 1255 (10.8) <.0001 40–49 1256 (31.5) 494 (25.3) 1208 (28.1) 432 (30.6) 3390 (29.1) 50–59 1378 (34.5) 626 (32.0) 1328 (30.9) 486 (34.4) 3818 (32.8) 60–69 707 (17.7) 452 (23.1) 940 (21.9) 247 (17.5) 2346 (20.1) 70–79 154 (3.9) 210 (10.7) 398 (9.3) 83 (5.9) 845 (7.3) Race White, non-Hispanic 3092 (85.0) 1479 (80.9) 3315 (85.6) 1087 (80.6) 8973 (83.9) <.0001 Black, non-Hispanic 53 (1.5) 63 (3.4) 174 (4.5) 35 (2.6) 325 (3.0) Hispanic 122 (3.4) 49 (2.7) 106 (2.7) 42 (3.1) 319 (3.0) Asian or Pacific Islander 256 (7.0) 170 (9.3) 185 (4.8) 139 (10.3) 750 (7.0) Other 115 (3.2) 68 (3.7) 94 (2.4) 45 (3.3) 322 (3.0) Missing 351 125 426 63 965 Family history of breast cancer No 1844 (48.3) 1372 (78.5) 2992 (72.0) 846 (63.5) 7054 (63.8) <.0001 Yes 1973 (51.7) 376 (21.5) 1161 (28.0) 486 (36.5) 3996 (36.2) Missing 172 206 147 79 604 Personal history of breast cancer No 489 (21.4) 26 (1.4) 1406 (44.7) 131 (14.7) 2052 (25.1) <.0001 Yes 1794 (78.6) 1822 (98.6) 1738 (55.3) 760 (85.3) 6114 (74.9) Missing, n 1706 106 1156 520 3488 Yes, assuming missing = no ∗ , % (45.0) (93.2) (40.4) (53.9) (52.5) <.0001 BI-RADS breast density Almost entirely fat 132 (4.6) 40 (3.2) 108 (3.4) 40 (4.2) 320 (3.9) <.0001 Scattered fibroglandular densities 885 (30.7) 402 (31.8) 980 (31.1) 241 (25.5) 2508 (30.4) Heterogeneously dense 1287 (44.7) 631 (49.9) 1612 (51.2) 452 (47.8) 3982 (48.3) Extremely dense 576 (20.0) 192 (15.2) 451 (14.3) 213 (22.5) 1432 (17.4) Missing 1109 689 1149 465 3412
BI-RADS, Breast Imaging Reporting and Data System; MRI, magnetic resonance imaging.
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MRI BI-RADS Assessments by Clinical Indication
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Table 2
Breast MRI BI-RADS Assessment by Clinical Indication
Assessment Clinical Indication Total Screening Extent of Disease Diagnostic Other_n_ (%) [95% CI]n (%) [95% CI]n (%) [95% CI]n (%) [95% CI]N (%) [95% CI] Total, N 3989 1954 4300 1411 11,654BI-RADS 1, 2, or 6∗3150 (79.0) [77.7–80.2]1335 ( 68.3) [66.2–70.4]3024 ( 70.3) [68.9–71.7]1025 ( 72.6) [70.2–75.0]8534 ( 73.2) [72.4–74.0] BI-RADS 1 990 (24.8) 16 (0.8) 1249 (29.0) 235 (16.7) 2490 (21.4) BI-RADS 2 2116 (53.0) 235 (12.0) 1416 (32.9) 647 (45.9) 4414 (37.9) BI-RADS 6 44 (1.1) 1084 (55.5) 359 (8.3) 143 (10.1) 1630 (14.0)BI-RADS 3422 ( 10.6) [9.6–11.6]194 ( 9.9) [8.6–11.3]517 ( 12.0) [11.1–13.0]198 ( 14.0) [ 12.3–16.0]1331 ( 11.4) [10.8–12.0]BI-RADS 0, 4, or 5∗417 ( 10.5) [9.5–11.4]425 ( 21.8) [ 19.9–23.6]759 ( 17.7) [16.5–18.8]188 ( 13.3) [11.6–15.2]1789 ( 15.4) [14.7–16.0] BI-RADS 0 144 (3.6) 88 (4.5) 147 (3.4) 42 (3.0) 421 (3.6) BI-RADS 4 259 (6.5) 246 (12.6) 455 (10.6) 126 (8.9) 1086 (9.3) BI-RADS 5 14 (0.4) 91 (4.7) 157 (3.7) 20 (1.4) 282 (2.4)BI-RADS 0, 3, 4, or 5∗839 ( 21.0) [19.8–22.3]619 ( 31.7) [29.6–33.8]1276 ( 29.7) [28.3–31.1]386 ( 27.4) [25.0–29.8]3120 ( 26.8) [26.0–27.6]
BI-RADS, Breast Imaging Reporting and Data System; CI, confidence interval; MRI, magnetic resonance imaging.
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Table 3
Trends in Breast MRI Abnormal Interpretation Rate by Clinical Indication and Year
Year(s) Clinical Indication Total Screening Extent of Disease Diagnostic Other Exams, n AIR, % Exams, n AIR, % Exams, n AIR, % Exams, n AIR, % Exams, n AIR, % Abnormal BI-RADS assessments: 0, 3, 4, or 5 2005–2006 655 19.1 361 27.4 1019 32.6 250 28.0 2285 27.4 2007 789 22.6 343 34.7 970 30.6 224 25.9 2326 28.0 2008 669 24.4 262 30.9 851 25.4 277 32.5 2059 26.7 2009 824 21.6 367 31.6 838 28.9 289 25.3 2318 26.3 2010 1052 18.5 621 32.9 622 30.4 371 25.6 2666 25.6P value trend .62 .18 .06 .48 Abnormal BI-RADS assessments: 0, 4, or 5 2005–2006 655 10.4 361 19.1 1019 21.7 250 16.0 2285 17.4 2007 789 11.0 343 23.3 970 19.8 224 12.1 2326 16.6 2008 669 12.9 262 21.4 851 12.8 277 15.2 2059 14.2 2009 824 8.9 367 18.3 838 15.5 289 9.7 2318 12.9 2010 1052 9.8 621 24.6 622 17.2 371 13.7 2666 15.5P value trend .36 .16 <.0001 .27
AIR, abnormal interpretation rate; BI-RADS, Breast Imaging Reporting and Data System; MRI, magnetic resonance imaging.
MRI examinations for 2005 and 2006 were combined because of lower number of examinations in the earliest years.
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Discussion
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Acknowledgments
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