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Diagnostic accuracy of digital mamography is improved in younger women
JOURNAL REVIEWS
Carol Snapp, CNM, MSN, DNSc
DIAGNOSTIC ACCURACY OF DIGITAL MAMOGRAPHY IS IMPROVED IN YOUNGER WOMEN Pisano ED, Gatsonis C, Hendrick E, Yaffee M, Baurn JK, Acharyya S, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med 2005;353:1–11. Reviewed by: Carol Snapp, CNM, MSN, DNSc. Screening mammography is recommended for women above age 40 or for those with certain risk factors. New technology uses a digital application of x-ray to enhance the reading of mammography, yet previous studies, with small sample sizes, have not found a significant difference between film mammography and newer digital mammography for screening. The Digital Mammographic Imaging Screening Trial (DMIST) study was designed to identify clinically significant differences between the use of traditional film mammography and digital mammography for screening. Over 49,500 women were recruited to participate in the study. This descriptive study included 33 centers. All experienced both types of mammography in random order. Exclusion criteria included pregnancy, having breast implants, a screening mammogram within the past 11 months, a palpable breast mass, bloody or clear nipple discharge, and previous breast cancer. The digital and film examinations were independently examined by different radiologists. A positive examination was one in which breast cancer was confirmed within 455 days after the initial mammography and negative for cancer if the follow-up mammogram at 1 year was considered normal. Confirmation of a positive or negative reading was also determined by biopsy. Data from 42,760 (86.7%) women were used in the final analysis. A total of 355 breast cancers were diagnosed in the DMIST cohort. In all women with verified cancer, the diagnostic accuracy was similar in both groups. However, differences arose between age groups and menopausal status. Digital mammography was more effective at identifying breast cancers in women less than 50 years of age (difference 0.15; 95% CI 0.05 to 0.25; I ⫽ .002), women who were classified as having heterogeneously dense or extremely dense breasts (difference 0.11; 95% CI 0.04 – 0.18; I ⫽ .003), and in premenopausal or perimenopausal women (difference 0.15; 95% CI 0.05– 0.24; I ⫽ .002). This study adds clarity to the current literature on the benefits and limitations of digital mammography. Digital mammography uses x-ray, much like conventional screen film mammography, but x-ray photons are absorbed by a phosphor material and converted to an electronic signal.1 This technology is designed for greater contrast resolution, especially in breasts classified as dense. Digital mammogJournal of Midwifery & Women’s Health • www.jmwh.org © 2006 by the American College of Nurse-Midwives Issued by Elsevier Inc.
raphy may be displayed on laser print film, cathode-ray anode, and transmitted electronically to distant sites. Currently, different strategies are under investigation to improve specificity and cost-effectiveness. Digital mammography is estimated to cost 2– 4 times what conventional film mammography costs.2 As with many new technologies, this cost may be reduced over time. The results of this study suggest there are no improved health benefits to women over 50 years of age or those who are postmenopausal. It may improve the ability of mammography to identify breast cancers in women who are less than 50 years of age, premenopausal, perimenopausal, or women whose breasts are classified as dense. The strength of this study is its large sample size, multicenter design, and strict adherence to screening regimen. However, this study did not address factors known to be correlated with breast cancer, such as family history, parity, or onset of menarche, among others, or any differences among racial or ethnic groups. African American women experience a higher rate of mortality related to breast cancer than white women with similar breast cancer classification. Therefore, it is important to identify screening techniques that effectively improve health outcomes of high-risk groups. This study contributes important information for certified nurse-midwives and certified midwives making screening recommendations for women. The authors note they will be reexamining this data for a cost-effectiveness study. Further data analyses, including examination of known breast cancer-related risk factors, will complement this clinically relevant study. REFERENCES 1. Parikh J. Digital mammography: current capabilities and obstacles. J Am Coll Radiol 2005;2:759 – 67. 2. Maidment ADA. Digital mammography: Coming of age. J Am Coll Radiol 2005;2:798 – 801.
CONJUGATED EQUINE ESTROGEN THERAPY DOES NOT IMPROVE HEALTH-RELATED QUALITY OF LIFE Brunner RL, Gass M, Aragaki A, Hays J, Granek I, Woods N, et al. Effects of conjugated equine estrogen on health-related quality of life in postmenopausal women with hysterectomy: Results from the Women’s Health Initiative Randomized Clinical Trial. Arch Intern Med 2005;165:1976 – 86. Reviewed by: Carol Snapp, CNM, MSN, DNSc. The purpose of this study was to measure health-related quality of life (HRQOL) in participants of the Women’s Health Initiative (WHI) relative to use of conjugated 59 1526-9523/06/$32.00
Carol Snapp, CNM, MSN, DNSc
DIAGNOSTIC ACCURACY OF DIGITAL MAMOGRAPHY IS IMPROVED IN YOUNGER WOMEN Pisano ED, Gatsonis C, Hendrick E, Yaffee M, Baurn JK, Acharyya S, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med 2005;353:1–11. Reviewed by: Carol Snapp, CNM, MSN, DNSc. Screening mammography is recommended for women above age 40 or for those with certain risk factors. New technology uses a digital application of x-ray to enhance the reading of mammography, yet previous studies, with small sample sizes, have not found a significant difference between film mammography and newer digital mammography for screening. The Digital Mammographic Imaging Screening Trial (DMIST) study was designed to identify clinically significant differences between the use of traditional film mammography and digital mammography for screening. Over 49,500 women were recruited to participate in the study. This descriptive study included 33 centers. All experienced both types of mammography in random order. Exclusion criteria included pregnancy, having breast implants, a screening mammogram within the past 11 months, a palpable breast mass, bloody or clear nipple discharge, and previous breast cancer. The digital and film examinations were independently examined by different radiologists. A positive examination was one in which breast cancer was confirmed within 455 days after the initial mammography and negative for cancer if the follow-up mammogram at 1 year was considered normal. Confirmation of a positive or negative reading was also determined by biopsy. Data from 42,760 (86.7%) women were used in the final analysis. A total of 355 breast cancers were diagnosed in the DMIST cohort. In all women with verified cancer, the diagnostic accuracy was similar in both groups. However, differences arose between age groups and menopausal status. Digital mammography was more effective at identifying breast cancers in women less than 50 years of age (difference 0.15; 95% CI 0.05 to 0.25; I ⫽ .002), women who were classified as having heterogeneously dense or extremely dense breasts (difference 0.11; 95% CI 0.04 – 0.18; I ⫽ .003), and in premenopausal or perimenopausal women (difference 0.15; 95% CI 0.05– 0.24; I ⫽ .002). This study adds clarity to the current literature on the benefits and limitations of digital mammography. Digital mammography uses x-ray, much like conventional screen film mammography, but x-ray photons are absorbed by a phosphor material and converted to an electronic signal.1 This technology is designed for greater contrast resolution, especially in breasts classified as dense. Digital mammogJournal of Midwifery & Women’s Health • www.jmwh.org © 2006 by the American College of Nurse-Midwives Issued by Elsevier Inc.
raphy may be displayed on laser print film, cathode-ray anode, and transmitted electronically to distant sites. Currently, different strategies are under investigation to improve specificity and cost-effectiveness. Digital mammography is estimated to cost 2– 4 times what conventional film mammography costs.2 As with many new technologies, this cost may be reduced over time. The results of this study suggest there are no improved health benefits to women over 50 years of age or those who are postmenopausal. It may improve the ability of mammography to identify breast cancers in women who are less than 50 years of age, premenopausal, perimenopausal, or women whose breasts are classified as dense. The strength of this study is its large sample size, multicenter design, and strict adherence to screening regimen. However, this study did not address factors known to be correlated with breast cancer, such as family history, parity, or onset of menarche, among others, or any differences among racial or ethnic groups. African American women experience a higher rate of mortality related to breast cancer than white women with similar breast cancer classification. Therefore, it is important to identify screening techniques that effectively improve health outcomes of high-risk groups. This study contributes important information for certified nurse-midwives and certified midwives making screening recommendations for women. The authors note they will be reexamining this data for a cost-effectiveness study. Further data analyses, including examination of known breast cancer-related risk factors, will complement this clinically relevant study. REFERENCES 1. Parikh J. Digital mammography: current capabilities and obstacles. J Am Coll Radiol 2005;2:759 – 67. 2. Maidment ADA. Digital mammography: Coming of age. J Am Coll Radiol 2005;2:798 – 801.
CONJUGATED EQUINE ESTROGEN THERAPY DOES NOT IMPROVE HEALTH-RELATED QUALITY OF LIFE Brunner RL, Gass M, Aragaki A, Hays J, Granek I, Woods N, et al. Effects of conjugated equine estrogen on health-related quality of life in postmenopausal women with hysterectomy: Results from the Women’s Health Initiative Randomized Clinical Trial. Arch Intern Med 2005;165:1976 – 86. Reviewed by: Carol Snapp, CNM, MSN, DNSc. The purpose of this study was to measure health-related quality of life (HRQOL) in participants of the Women’s Health Initiative (WHI) relative to use of conjugated 59 1526-9523/06/$32.00