Abstract PS05-06: Outcomes of Surveillance using Contrast Enhanced Mammography in Women with a Personal History of Breast Cancer
Authors: Matheson Julia , Nickson Carolyn , Elder Kenneth , Park Allan , Rose Allison , Mann Bruce 
Published: May 2024

Abstract
Background
Women with a personal history of breast cancer (PHBC) have a high rate of subsequent breast malignancy. Annual mammography with selective ultrasound has been the standard method of surveillance after breast cancer for many years, aiming for early detection, treatment and improved survival. In surveillance populations, interval cancers, which can account for ~30% of subsequent breast cancers, are more likely to be larger, hormone receptor negative and lymph node positive than cancers detected by surveillance (Lee et al, Radiology 2021). Interval cancer rates of 3.6 per 1000 mammographic screens have been reported previously in women with PHBC (Houssami et al, JAMA 2011).
For women with PHBC a more sensitive surveillance approach may be justified, noting mammography has lower program sensitivity in PHBC surveillance than in screening. Magnetic resonance imaging (MRI) is used selectively but with resource and access limitations. Contrast enhanced mammography (CEM) offers a more sensitive modality than conventional mammography with specificity comparable to MRI, but its utility for surveillance is uncertain.
Methods
Retrospective study of 1,190 women with PHBC who commenced annual CEM surveillance in an Australian hospital setting between June 2016 and December 2022 (Elder et al, Breast Cancer Res Treat 2023) combining outcomes of initial CEM and any subsequent surveillance imaging over that period, including incident surveillance-detected cancers and interval cancers (cancers diagnosed in the year following a negative surveillance episode), recalls for assessment, the contribution of contrast to recall, and pathology and treatment details for cancer diagnoses. Outcomes were reported using descriptive statistics and hazards modelling.
Results
There were 3,784 episodes for analysis: 1,190 first CEM surveillance episodes, and 2,594 subsequent surveillance episodes of which &gt;90% were contrast based imaging. 79% of women had at least three annual rounds of surveillance imaging.
186 cases from the total 3784 surveillance episodes were recalled for assessment (recall rate 4.9%). 72 (39%) recalled cases identified malignant lesions (true positives (TP)), with 50 invasive cancers and 22 cases of DCIS. 114 (61%) recalled cases were false positives (FP). 51% of cases were only recalled due to contrast and 35% of these were TP.
Invasive cancers were predominantly stage 1 (64%) or stage 2 (32%) and most were grade 2 (44%) or grade 3 (47%). The median invasive cancer size was 16mm (IQR 9-25mm). 62% of invasive cancers were hormone receptor positive HER2 negative, and 24% were triple negative. The median DCIS size was 19mm (IQR 10-26mm) with only a single low grade case. 40% of invasive cancers and 59% of DCIS were recalled due to contrast. Comparison of tumour features indicates similarities between contrast-directed recalls and other diagnoses; conclusive findings would require a larger sample.
Five interval cancers were identified, of which three were asymptomatic and detected on surveillance imaging scheduled early for other reasons. Thus, the rate of symptomatic interval cancers was 0.8 per 1000 screens (program sensitivity 96.0%).
Surveillance-detected cancer rates differed significantly by index cancer subtype (χ2=11.9, p=0.0026), with highest rates for women with triple negative index cancers. Incidence cancer rates were higher among the 6.9% of women with moderate or marked BPE at first CEM surveillance episode (χ2=8.8, p=0.032), but did not differ significantly by age group (χ2=5.2, p=0.39) nor breast density (χ2=4.7, p=0.19).
Conclusions
Routine use of CEM in annual surveillance of women with PHBC led to 1.85-fold increase in the detection of clinically significant malignant lesions, with lower interval cancer rates than previous published series of women with PHBC. CEM appears to increase the sensitivity of surveillance programs for women with PHBC, improving on imaging without contrast.
Citation Format: Julia Matheson, Carolyn Nickson, Kenneth Elder, Allan Park, Allison Rose, Bruce Mann. Outcomes of Surveillance using Contrast Enhanced Mammography in Women with a Personal History of Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS05-06.