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Rate of Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection

CBE ID
4700e
Endorsement Status
E&M Committee Rationale/Justification

When the measure returns for maintenance (3 years), the measure developer should have:

  • Conducted additional validity testing (data element in additional EHR); and
  • Continued to monitor (e.g., qualitative assessments, empirical analyses) for unintended consequences (e.g., reduced access to mammography) during implementation.
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2027
1.6 Measure Description

This electronic Clinical Quality Measure (eCQM) reports the percentage of female patients aged 40 to 75 years with at least one abnormal screening (BI-RADS 0) or screening-to-diagnostic (BI-RADS 4, 5) mammogram during the measurement period (i.e., calendar year) who received timely diagnostic resolution defined as either follow-up imaging with negative/benign/probably benign results or a breast biopsy within 60 days after their index (i.e., first) abnormal screening mammogram.

Negative/benign/probably benign follow-up imaging was defined as diagnostic mammography, breast ultrasound or magnetic resonance imaging (MRI) with BI-RADS ratings of 1, 2, or 3. Relevant diagnostic breast biopsy procedures were defined as core needle biopsy, fine needle aspiration, and surgical excision.

Breast Imaging – Reporting and Data System (BI-RADS) ratings: 0-incomplete, 1-negative, 2-benign, 3-probably benign, 4-suspicious, 5-highly suggestive of malignancy.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.8b Other Level of Analysis
Integrated Delivery System
1.9 Care Setting
1.9b Other Care Setting
Integrated Delivery System
1.10 Measure Rationale

Breast cancer is the second most common cause of cancer deaths among women in the United States [1]. In 2024, around 42,250 women will die from breast cancer and an estimated 310,720 new cases of invasive breast cancer will be diagnosed [1].

Breast cancer survival is dependent upon cancer stage at diagnosis. Approximately 99% of women diagnosed with early-stage breast cancer live for five years or more [2]. However, this applies to only about 32% of those diagnosed at the most advanced stage. 

Noninvasive mammographic screening is the primary screening modality used to detect breast cancer. Delays in diagnostic follow-up after abnormal mammographic screening results increase the risk of diagnosing cancer at a more advanced stage [3]. 

National screening guidelines recommend that women with abnormal screening mammogram results (BI-RADS 0, 4, or 5) undergo additional follow-up imaging via diagnostic mammography, magnetic resonance imaging (MRI), and/or ultrasound [4, 5, 6, 7]. While it is recommended that patients with a benign follow-up imaging result return to routine screening, those with abnormal results (BI-RADS 4 or 5) should have diagnostic samples extracted (e.g., via percutaneous biopsy, fine needle aspiration, or surgical excision) from a suspicious area to evaluate for cancer [4]. 

Expert-based quality measure programs support the need to establish a reasonable timeframe that encompasses this multi-step process. According to the Center for Disease Control and Prevention (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP), breast cancer screening to diagnostic resolution should occur within 60 days [8]. It is also expected that over 90% of women complete diagnostic resolution after an abnormal screening mammogram [8, 9]. Published literature shows that long wait times to diagnostic evaluation are associated with increased tumor size and lymph node metastases in patients with delays exceeding 12 weeks [10, 11, 12].

Disparities in diagnostic follow-ups after abnormal screening mammograms are frequently reported in the literature. A 2021 systematic review reported rates of failure to follow-up on abnormal screening mammograms ranging from 7.2-33% [13]. A 2024 study on the American College of Radiology’s National Mammography Database (NMD) observed that only 66.4% of 2.9 million abnormal screening mammograms (BI-RADS 0) documented from 2008-2021 had diagnostic follow-up [14]. In this cohort, women with no family history of breast cancer had lower follow-up rates, Black and Native American women had lower overall follow-up rates and lower biopsy rates [14]. Rural and community hospital-affiliated facilities had longer median times to biopsy [14]. 

The variability in follow-up rates in the NMD and existing literature imply the existence of barriers limiting mammography facilities from carrying out complete diagnostic resolution within a timely manner for all patients. This eCQM can be used to address quality assessment gaps by monitoring timeliness and completeness of care in medical facilities and health systems looking to improve the breast cancer screening diagnostic process.

  1. Key Statistics for Breast Cancer. American Cancer Society. Updated January 17, 2024. Accessed October 31, 2024. https://www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breast-cancer.html.
  2. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on 2021 submission data (1999–2020): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. Updated June 2024. Accessed July 2024. www.cdc.gov/cancer/dataviz.
  3. McCarthy AM, Kim JJ, Beaber EF, et al. Follow-Up of Abnormal Breast and Colorectal Cancer Screening by Race/Ethnicity. Am J Prev Med. 2016;51(4):507-512. doi:10.1016/j.amepre.2016.03.017. PMID: 27132628.
  4. Sickles E, D’Orsi CJ. ACR BI-RADS follow-up and outcome monitoring. In: D’Orsi CJ, ed. ACR BI-RADS atlas, breast imaging reporting and data system. Reston, VA: American College of Radiology Reston; 2013:5-67. https://www.acr.org/-/media/ACR/Files/RADS/BI-RADS/BIRADSFAQ.pdf.
  5. Monticciolo DL, Malak SF, Friedewald SM, et al. Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging. J Am Coll Radiol. 2021;18(9):1280-1288. doi:10.1016/j.jacr.2021.04.021. PMID: 34154984.
  6. US Preventive Services Task Force, Nicholson WK, Silverstein M, et al. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement [published correction appears in JAMA. 2024 Sep 30. doi: 10.1001/jama.2024.19851]. JAMA. 2024;331(22):1918-1930. doi:10.1001/jama.2024.5534. PMID: 38687503.
  7. Esserman LJ, Joe BN, et al. Diagnostic evaluation of suspected breast cancer. UpToDate. Updated October 31, 2023. Accessed October 31, 2024. https://www.uptodate.com/contents/diagnostic-evaluation-of-suspected-breast-cancer?search=birads&source=search_result&selectedTitle=2%7E13&usage_type=default&display_rank=2#H24.
  8. DeGroff A, Royalty JE, Howe W, et al. When performance management works: a study of the National Breast and Cervical Cancer Early Detection Program. Cancer. 2014;120 Suppl 16(Suppl 16):2566-2574. doi:10.1002/cncr.28817. PMID: 25099899.
  9. Miller JW, Hanson V, Johnson GD, Royalty JE, Richardson LC. From cancer screening to treatment: service delivery and referral in the National Breast and Cervical Cancer Early Detection Program. Cancer. 2014;120 Suppl 16(0 16):2549-2556. doi:10.1002/cncr.28823. PMID: 25099897.
  10. Olivotto IA, Gomi A, Bancej C, et al. Influence of delay to diagnosis on prognostic indicators of screen-detected breast carcinoma. Cancer. 2002;94(8):2143-2150. doi:10.1002/cncr.10453. PMID: 12001110.
  11. Ganry O, Peng J, Dubreuil A. Influence of abnormal screens on delays and prognostic indicators of screen-detected breast carcinoma. J Med Screen. 2004;11(1):28-31. doi:10.1177/096914130301100107. PMID: 15006111.
  12. Doubeni CA, Gabler NB, Wheeler CM, et al. Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium. CA Cancer J Clin. 2018;68(3):199-216. doi:10.3322/caac.21452. PMID: 29603147.
  13. Reece JC, Neal EFG, Nguyen P, McIntosh JG, Emery JD. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC Cancer. 2021;21(1):373. Published 2021 Apr 7. doi:10.1186/s12885-021-08100-3. PMID: 33827476.
  14. Oluyemi ET, Grimm LJ, Goldman L, et al. Rate and Timeliness of Diagnostic Evaluation and Biopsy After Recall From Screening Mammography in the National Mammography Database. J Am Coll Radiol. 2024;21(3):427-438. doi:10.1016/j.jacr.2023.09.002. PMID: 37722468.
1.20 Types of Data Sources
1.20a Other Data Source
MagView Mammography Software Systems & Solutions (Breast Center Analytics)
1.25 Data Source Details

Health System 1 data were used to calculate the eCQM rates, assess feasibility, and conduct reliability and validity testing. All analyses were conducted using data routinely collected and documented in the Epic EHR and reported for six years (2018 to 2023). Six facility groups were included in the analyses.

Health System 2 data were used to calculate eCQM rates and assess feasibility. All analyses were conducted using data routinely collected and documented in the Cerner (now Oracle Health) EHR and reported for six years (2018 to 2023). One facility group was included in the analyses.

Health System 3 data were used to assess feasibility using the Allscripts EHR. eCQM rates are forthcoming.