NURS B412 FINAL EXAM QUESTIONS AND ANSWERS

NURS B412 FINAL EXAM QUESTIONS AND ANSWERS.Ultrasound for Breast Cancer Detection GloballyA Systematic Review and Meta-Analysis Rupali Sood, MPH1,2; Anne F. Rositch, PhD3 ; Delaram Shakoor, MD1 ; Emily Ambinder, MD1 ; Kara-Lee Pool, MD2,4; Erica Pollack, MD2,5; Daniel J. Mollura, MD2 ; Lisa A. Mullen, MD 1 ; and Susan C. Harvey, MD1,2 a b s t r a c t PURPOSE Mammography is not always available or feasible. The purpose of this systematic review and metaanalysis is to assess the diagnostic performance of ultrasound as a primary tool for early detection of breast cancer. MATERIALS AND METHODS For this systematic review and meta-analysis, we comprehensively searched Puband SCOPUS to identify articles from January 2000 to December 2018 that included data on the performance ofultrasound for detection of breast cancer. Studies evaluating portable, handheld ultrasound as an independent detection modality for breast cancer were included. Quality assessment and bias analysis were performed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Sensitivity analyses and meta-regression were used to explore heterogeneity. The study protocol has been registered with the international prospective registerof systematic reviews (PROSPERO identifier: CRD52). RESULTS Of the 526 identified studies, 26 were eligible for inclusion. Ultrasound had an overall pooled sensitiviand specificity of 80.1% (95% CI, 72.2% to 86.3%) and 88.4% (95% CI, 79.8% to 93.6%), respectively. When only low- and middle-income country data were considered, ultrasound maintained a diagnostic sensitivity of 89.2% and specificity of 99.1%. Meta-analysis ofthe included studies revealed heterogeneity.The high sensitivity of ultrasound for the detection of breast cancer was not statistically significantly different in subgroup analyses on the basis of mean age, risk, symptoms, study design, bias level, and study setting. CONCLUSION Given the increasing burden of breast cancer and infeasibility of mammography in certain settingwe believe these results support the potential use of ultrasound as an effective primary detection tool for breast cancer, which may be beneficialin low-resource settings where mammography is unavailable. J Global Oncol. © 2019 by American Society of Clinical Oncology Creative Commons Attribution Non-CommercialNo Derivatives 4.0 License INTRODUCTION Breast cancer is the leading cause of cancer-related deaths among females worldwide. In 2018, 2.1 million new breast cancer cases and 626,679 deaths were reported.1 Adequate access to detection of breast cancer with imaging is the first step in the diagnostic pathway to decrease mortality from this disease. Mammography, which has long been considered the gold standard for screening and early detection of breast cancer, is not always feasible, especially in limited-resource settings. This may be due to the high cost of purchasing and maintaining equipment as well as difficulty training and retaining skilled technologists and interpreting radiologists.Data from 2014 show that that per 1 million women between 50 and 69 years old, highly developed areas of the world have anywhere from 40 to 600 mammography units, whereas there is an average of 0 to 12 mammography units in most of sub-Saharan Africa and approximately 12 to 41 units in many developing areas in Asia. 2 In the United States,where 70% of women undergo mammography, the most recent estimates of the overall sensitivity and specificity of diagnostic digital mammography are 87.8% and 90.5%, respectively.3,4 In low- and middle-income countries (LMICs), the reported sensitivity of mammography ranges from 63% to 95%; higher sensitivity is seen when examining palpable lumps, and lower sensitivity is seen in cases of dense breasts.4 Breast ultrasound, which is used in high-resource settings to supplement mammography in certain clinical scenarios, offers a potentially viable alternative for early breast cancer detection in some resourcelimited areas because itis portable, lower cost than mammography, and versatile across a wider range of clinical applications. Breast ultrasound has been proven to be an exceptionally effective tool for imaging palpable abnormalities in the breast.It distinguishes ASSOCIATED CONTENT Data Supplement Author affiliations and support information (if applicable) appear at the end of this article. Accepted on July 11, 2019 and published at jgo on August 27, 2019: DOI https://doi. org/10.1200/JGO.19. 00127 1 Downloaded from by 68.251.34.27 on October 2, 2022 from 068.251.034.027 Copyright © 2022 American Society of Clinical Oncology. See cystic from solid masses and demonstrates those features of solid masses that would denote the mass as suspicious and warranting biopsy. 5-7 Ultrasound is a particularly useful diagnostic modality in dense breast tissue, often detecting breast cancers obscured on mammography.8,9 Furthermore, if biopsy is required, ultrasound is the ideal imaging tool to guide subsequent procedures, further enhancing its utility in breast cancer diagnosis.5-7 The deployment of ultrasound as a diagnostic modality could be most helpful in LMICs, because they carry a disproportionate burden ofdisease.In 2012, 52.9% of the 1.7 million breast cancer cases were classified as global, and 62.1% of the breast cancer–related deaths occurred in LMICs.10 Although breast cancer incidence is highest in high-income countries, mortality rates are lower in these locations as a result of advances in early detection, diagnosis, and treatment. 11,12 In 2018, the age-standardized incidence rate of breast cancer (per 100,000 women) in Northern America was 84.8, with a mortality rate (per 100,000 women) of 12.6, whereas for Western Africa the estimates were 37.3 and 17.8, respectively. 1 It is estimated that by 2020, 70% of all breast cancer cases worldwide will occur in LMICs, with a projected estimate to more than 1 million new cases per year in these areas. 5,13 These disproportionately high mortality-to-incidence ratios in LMICs are due to scarcity of available detection, diagnosis, and treatment of breast cancer.14,15 It must also be acknowledged that data are severely lacking in LMICs, which can result even in an underestimation of the disease burden and barriers to care in these areas.16 This situation is further exacerbated by insufficientpatient education about breast health and the importance of early detection.5,14 Identifying breastcancer at an early stage, before local, regional, or systemic spread,offers the potential for initiation of earlier, more effective treatment and is thus vital to improving outcomes in LMICs. 6 Although the literature consistently reports increased breast cancer detection with use ofsupplementary screening ultrasound, few direct comparisons of mammography and ultrasound for average-risk patients have been reported. 3 The purpose of this systematic review and meta-analysis is to assess the potential of ultrasound, indicated by sufficiently high diagnostic performance against histologic confirmation and benchmarked against the highly accepted performance of mammography, for breast cancer detection, which could be particularly applicable in LMICs. MATERIALS AND METHODS Search Strategy and Selection Criteria We conducted a systematic literature review and metaanalysis following Cochrane Guidelines for Screening and Diagnostic tests and the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We identified eligible studies in PubMed and Scopus (Amsterdam, the Netherlands) published between January 2000 and December 2018. The search was designed to identify all studies in which ultrasound was evaluated as a primary detection modality for breast cancer, both in a screening and diagnostic capacity. A comprehensive search strategy including free textand MeSH terms was developed in consultation with an experienced librarian specialist. Search terms included: “breast neoplasms,” “breast cancer,” “breast lesions,” “mammary ultrasound,” “breast ultrasound,” “breast diagnostic,” “mammography,” “low resource,” and “screening.” Titles and abstracts were screened to determine primary eligibility on the basis of the Preferred Reporting Items for Systematic reviews and MetaAnalysis algorithm (Fig 1). Reference lists of the retrieved publications were also screened for any additional relevant studies. If there were several publication reports for a specific study, the author was contacted to determine which study was most comprehensive for inclusion in this meta-analysis. The inclusion criteria were discussed between authors, and joint consensus was achieved. The studies eligible for inclusion in this systematic review and meta-analysis were peer-reviewed studies in human participants in which portable ultrasound was evaluated as a primary detection modality for breast cancer. The search was restricted to CONTEXT Key Objective Is portable ultrasound a viable breast cancer detection modality? Knowledge Generated A comprehensive literature review and meta-analysis revealed portable ultrasound to have an overall high sensitivity of 80.1% and specificity of 88.4% for detection of breast cancer in a variety of patient populations. When the available data from lowresource countries were considered, ultrasound maintained a diagnostic sensitivity of 89.25% and specificity of 99.1%. Relevance Portable ultrasound could serve as a global primary detection modality and triage method for breast lesions, particularly in lowresource areas where mammography is currently unavailable or infeasible. Sood et al 2 © 2019 by American Society of Clinical Oncology Downloaded from by 68.251.34.27 on October 2, 2022 from 068.251.034.027 Copyright © 2022 American Society of Clinical Oncology. See English language articles, and studies with portable ultrasound estimates were included. Prospective, retrospective, and cross-sectionalstudies published between January 2000 and December 2018 were included. The required reference standard was biopsy with histopathology results. Each manuscript was required to have extractable data to calculate true positives, false negatives, true negatives, and false positives so that sensitivity, specificity, positive predictive value, and negative predictive value (NPV) could be determined. Studies that compared mammography and ultrasound against verified histopathology were included,and data for both modalities were extracted. In comparative studies with other modalities, such as automated whole-breast ultrasound or magnetic resonance imaging,only handheld ultrasound estimates were extracted. Studies in populations with proven breast cancers were excluded, because they were deemed to bias diagnostic accuracy of the modality being evaluated. In addition, any study in which ultrasound was automated or examined only as a supplemental diagnostic modality, such as after mammography or magnetic resonance imaging screening, with only combined estimates recorded, were excluded. Studies in mammographically negative tissue with ultrasound diagnostic parameter values were included. When authors were unable to extract data for diagnostic parameter estimate calculations, primary authors of the considered article were contacted for clarification and raw data. In addition, duplicate articles were removed based on verified author, journal, title, and year of the study. Data Extraction and Quality Assessment One investigator(R.S.) extracted all study demographic data, including study type, study country, study setting, population, mean age, positive case definition, blinded image interpretation,and reference standard from each study. Two investigators (R.S.and D.S.) extracted data related to the number of ultrasound and mammography examinations,including quantification of true positives, true negatives, false positives,and false negatives. Two independent readers (R.S. and S.C.H.) performed the quality assessment and bias analysis with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.17 Three domains were used to identify applicability concerns and risk for bias: patient selection, performance of index test, and standard of reference. Discrepancies were resolved by consensus review or a third reader (D.S.). Each study was given a final designation of low or high bias on the basis of these categories. Data Analyses Meta-analysis for assessing the diagnostic performance of ultrasound alone and also comparatively between ultrasound and mammography was conducted using STATA (version 15; STATA, College Station, TX). Extracted data for all included studies were pooled to yield summary estimates of sensitivity and specificity of ultrasound for detection of breast cancer. Heterogeneity was investigated with calculated Higgins I2 values,with greater than 50% considered indicative ofsubstantialheterogeneity among studies.18 Forest plots were drawn to visually represent Screening Included Eligibility Identification Records identified through database searching (n = 510) Additional records identified through other sources (n = 47) Records excluded: Not relevant No full text available (n = 432) (n = 94) Full-text articles excluded: Guidelines and literature reviews No diagnostic data Non-handheld ultrasound Ultrasound as adjunct Ultrasound results not clearly reported Known BC patient population Follow-up/procedural setting Duplicate data sets (n = 17) (n = 10) (n = 8) (n = 8) (n = 5) (n = 5) (n = 3) (n = 3) Records after duplicates removed (n = 526) Records screened (n = 526) Full-text articles assessed for eligibility (n = 85) Studies included in systematic review and meta-analysis (n = 26) FIG 1. Flowchart of study selection. BC, breast cancer