|J Pathol Inform 2017,
A randomized study comparing digital imaging to traditional glass slide microscopy for breast biopsy and cancer diagnosis
Joann G Elmore1, Gary M Longton2, Margaret S Pepe3, Patricia A Carney4, Heidi D Nelson5, Kimberly H Allison6, Berta M Geller7, Tracy Onega8, Anna N. A Tosteson9, Ezgi Mercan10, Linda G Shapiro10, Tad T Brunyé11, Thomas R Morgan1, Donald L Weaver12
1 Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
2 Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
3 Fred Hutchinson Cancer Research Center, Seattle, WA 98109; Department of Biostatistics, University of Washington School of Public Health, Seattle, WA 98104, USA
4 Department of Family Medicine, Oregon Health and Science University, Portland, OR 97239, USA
5 Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239; Providence Cancer Center, Providence Health and Services Oregon, Portland, OR 97213, USA
6 Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
7 Department of Family Medicine, University of Vermont, Burlington, VT 05405, USA
8 Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
9 The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
10 Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
11 Department of Psychology, Tufts University, Medford, MA 02155, USA
12 Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT 05405, USA
|Date of Submission||27-Oct-2016|
|Date of Acceptance||18-Jan-2017|
|Date of Web Publication||10-Mar-2017|
Joann G Elmore
University of Washington, 325 Ninth Avenue, Box 359780, Seattle, WA 98104-2499
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Digital whole slide imaging may be useful for obtaining second opinions and is used in many countries. However, the U.S. Food and Drug Administration requires verification studies. Methods: Pathologists were randomized to interpret one of four sets of breast biopsy cases during two phases, separated by ≥9 months, using glass slides or digital format (sixty cases per set, one slide per case, n = 240 cases). Accuracy was assessed by comparing interpretations to a consensus reference standard. Intraobserver reproducibility was assessed by comparing the agreement of interpretations on the same cases between two phases. Estimated probabilities of confirmation by a reference panel (i.e., predictive values) were obtained by incorporating data on the population prevalence of diagnoses. Results: Sixty-five percent of responding pathologists were eligible, and 252 consented to randomization; 208 completed Phase I (115 glass, 93 digital); and 172 completed Phase II (86 glass, 86 digital). Accuracy was slightly higher using glass compared to digital format and varied by category: invasive carcinoma, 96% versus 93% (P = 0.04); ductal carcinoma in situ (DCIS), 84% versus 79% (P < 0.01); atypia, 48% versus 43% (P = 0.08); and benign without atypia, 87% versus 82% (P < 0.01). There was a small decrease in intraobserver agreement when the format changed compared to when glass slides were used in both phases (P = 0.08). Predictive values for confirmation by a reference panel using glass versus digital were: invasive carcinoma, 98% and 97% (not significant [NS]); DCIS, 70% and 57% (P = 0.007); atypia, 38% and 28% (P = 0.002); and benign without atypia, 97% and 96% (NS). Conclusions: In this large randomized study, digital format interpretations were similar to glass slide interpretations of benign and invasive cancer cases. However, cases in the middle of the spectrum, where more inherent variability exists, may be more problematic in digital format. Future studies evaluating the effect these findings exert on clinical practice and patient outcomes are required.
Keywords: Breast cancer, diagnostic accuracy, digital whole-slide imaging, intraobserver reproducibility
|How to cite this article:|
Elmore JG, Longton GM, Pepe MS, Carney PA, Nelson HD, Allison KH, Geller BM, Onega T, Tosteson AN, Mercan E, Shapiro LG, Brunyé TT, Morgan TR, Weaver DL. A randomized study comparing digital imaging to traditional glass slide microscopy for breast biopsy and cancer diagnosis. J Pathol Inform 2017;8:12
|How to cite this URL:|
Elmore JG, Longton GM, Pepe MS, Carney PA, Nelson HD, Allison KH, Geller BM, Onega T, Tosteson AN, Mercan E, Shapiro LG, Brunyé TT, Morgan TR, Weaver DL. A randomized study comparing digital imaging to traditional glass slide microscopy for breast biopsy and cancer diagnosis. J Pathol Inform [serial online] 2017 [cited 2017 Aug 23];8:12. Available from: http://www.jpathinformatics.org/text.asp?2017/8/1/12/201920
| Introduction|| |
Cancer diagnoses rely on a pathological interpretation of biopsy tissue using traditional glass slide microscopy. The process frequently involves obtaining second opinions before initiating treatment. Numerous prior studies have shown that more than 10% of breast biopsy diagnoses are changed after obtaining a second review.,,,,, Digital whole-slide imaging (WSI) has the potential to transform the diagnostic process by creating high-resolution digital images of glass slides that are easily transported electronically and viewable on a computer monitor with pan and zoom features, which emulates screening a glass slide at varied magnification. The digital format has replaced the microscope in many medical schools, clinical conferences, and medical board tests ,, and is diffusing into clinical practices for telemedicine and archiving, including rapid retrieval. Telepathology using digital WSI could accelerate pathology consultations and aid the field of oncology.
While the digital format is increasingly used internationally in Europe and Canada,,,,,,, it is not approved by the Food and Drug Administration (FDA) for primary diagnostic interpretation in the U.S. Although several studies report promising outcomes using digital WSI, often fewer than 12 pathologists participated in these studies, or participating pathologists were experts in their clinical field, and the spectrum of cases was often limited to just a few diagnostic categories or prototypical cases.,,,,,,,, More robust studies will be required by the FDA to sufficiently validate digital WSI technology.
The digital format may be particularly useful for breast specimens given the high volume of biopsies  and challenges associated with interpreting breast pathology.
In this prospective randomized study, we evaluate the results of 208 practicing U.S. pathologists randomly assigned to interpret breast biopsy specimens in either traditional glass slide or digital WSI format. We also evaluate the potential for improvement with experience using the digital format during their test set interpretation, and we calculate the predictive value of cases interpreted using digital WSI by estimating the likelihood of diagnostic confirmation by a reference consensus panel.
| Methods|| |
Institutional review boards
The Institutional Review Boards at Fred Hutchinson Cancer Research Center (#9249), the University of Vermont (#M13-269), and the University of Washington (#43717) approved all study activities. Pathologists provided informed consent. All activities were HIPAA compliant.
Test case development
Test set case development and study design are previously described.,,, Briefly, 240 breast biopsy specimens were randomly selected from pathology registries. Each case included standardized data on the woman's age at biopsy, breast density, and biopsy type. We oversampled cases with atypia (atypical ductal hyperplasia [ADH] and ADH in a papilloma) and ductal carcinoma in situ (DCIS), biopsies from women aged 40–49 years, and cases from women with dense breasts. Nearly half of the 240 cases were from women aged 40–49 years (n = 118); the remainder were from women aged 50–59 years (n = 67), 60–69 years (n = 29), and >70 years (n = 26). Breast Imaging-Reporting and Data System breast density categories assessed on the previous mammography included almost entirely fat (n = 13), scattered fibroglandular densities (n = 105), heterogeneously dense (n = 97), and extremely dense (n = 25). Cases were from both core needle (n = 138) and excisional (n = 102) biopsies. The 240 cases were randomly assigned to one of four test sets, with stratification to achieve balance for these factors.
Each glass slide was scanned using an iScan Coreo Au ® digital slide scanner in 40× high-resolution mode. A technician and an experienced breast pathologist reviewed each digital image, rescanning as needed to obtain the highest quality. A custom online digital slide viewer was built using HD View SL, Microsoft's open source Silverlight gigapixel image viewer. The viewer, like popular online mapping applications and industry-sponsored WSI viewers, allowed pathologists to pan the image and zoom (up to 40× actual scanned magnification with additional digital magnification for a final maximum magnification of 60×). Additional tools were available for measuring lesion size and counting mitotic figures.
Determination of reference standard
Three experienced breast pathologists developed a reference interpretation by consensus agreement for each case in glass format using standardized diagnostic categories. The case distribution, defined by glass slide reference categories, was: benign without atypia (30%), atypia (30%), DCIS (30%), and invasive carcinoma (10%). We present all data in comparison to the glass slide reference diagnoses. Reference panel members independently interpreted all cases again in digital format approximately 19 months after glass slide interpretation and established a digital format reference diagnosis.
Pathologist recruitment, selection, and baseline data collection
The study pathologists were recruited from eight U.S. states (AK, ME, MN, NH, NM, OR, VT, and WA), had completed residency training, had interpreted breast specimens for ≥1 year, and intended to continue interpreting breast specimens for ≥1 year. Pathologists were invited to participate through E-mail(s), subsequent mail invitations, and telephone calls. After enrolling, pathologists completed a demographic and practice characteristic survey.
Test case interpretations
Pathologists were randomly assigned to a test set and interpretive format (glass slide vs. digital) for Phase I, stratified by clinical expertise (defined by self-reported expertise in breast pathology and/or completion of a breast pathology fellowship). All interpretations were performed by pathologists using their own microscopes and computers. After at least 9 months, the pathologists were invited to interpret cases in Phase II. The pathologists were again randomly assigned to interpretive format in Phase II, with stratification based on Phase I format and clinical expertise [Figure 1] and [Appendix 1 [Additional file 1]].
|Figure 1: Flow diagram for pathologist randomization [see Appendix 1 for further details on recruitment and randomization]|
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The pathologists interpreted the same cases in both phases; however, the cases were randomly ordered for each participant and also for each phase. Pathologists were not informed that the cases in Phase II were the same exact, reordered cases they had already interpreted in Phase I. Pathologists used a web-based form to document interpretations and indicate whether they desired a second opinion for each case., Pathologists received up to 20 hours of Category 1 Continuing Medical Education (CME) credits after participating.
We calculated case agreement rates for Phase I with the reference diagnoses as a measure of accuracy for glass and digital format. A priori, we planned to use Phase I data only when comparing accuracy to avoid assumptions about carryover effects from Phase I to Phase II and because we had sufficient statistical power from Phase I data. Tests for agreement rates and confidence intervals (CIs) accounted for both within- and between-participant variability by employing variance estimates of the form (var [ratep] + [avg (ratep) × (1 – avg (ratep))]/nc)/np, where avg (ratep) is the average rate among pathologists, var (ratep) is the sample variance among pathologists, nc is the number of cases interpreted by each pathologist, and np is the number of pathologists. Effects of pathologist characteristics (e.g., expertise, digital experience) and case characteristics (e.g., patient age, biopsy type) on accuracy were examined. Results of the 6-point Likert scales for confidence and difficulty ratings were simplified to a binary variable of 1, 2, 3 versus 4, 5, 6.
When rate comparisons involved more than one factor or more than two levels for a single factor, we used logistic regression models of agreement rates with a robust variance estimator to account for the lack of independence between interpretations by the same pathologist.
We used logistic regression to examine if the effect on accuracy of glass versus digital format remained after adjusting for pathologist characteristics. Adjusting for case-level characteristics was unnecessary, as pathologists interpreted the same cases, eliminating the potential for case-level characteristics to confound the glass versus digital comparison.
We evaluated whether a learning curve existed as pathologists became more experienced using the digital format during this study. In this analysis, the average pathologist-level accuracy was estimated separately for each of the six consecutive subsets of ten cases in a pathologist's sequence of cases. We used logistic regression with an ordered covariate with values one to six indicating interpretive sequence (i.e., group of ten cases) to determine if there was an increasing trend.
To assess reproducibility, pathologists' interpretations in Phase II were compared with their interpretations of the same cases in Phase I. Agreement rates and CIs were based on logit models utilizing a robust estimator of the variance to account for correlation of case interpretations from the same pathologist. Differences in reproducibility (agreement rates) were calculated when using glass slides in both phases, when using digital format in both phases, and when the format changed between phases (e.g., using glass slides in one phase and digital in the other). Hypothesis tests were based on Wald tests of logit model coefficients distinguishing between interpretations made on different combinations of diagnostic formats.
We calculated the probability that an initial biopsy interpretation in clinical practice using the digital format would be confirmed by the reference diagnosis (i.e., the predictive value). We used previously described techniques  combining the Phase I data with the prevalence of diagnostic outcomes in U.S. women 50–59 years old who received breast biopsies after screening.
| Results|| |
Characteristics of participating pathologists
Of responding pathologists, 252 (65%) were eligible and agreed to participate [Figure 1] and [Appendix 1 [Additional file 2]]. Between participating pathologists and those who declined or whom we were unable to contact, there were no statistically significant differences in mean pathologist age, sex, or the proportion working in a population of 250,000 or more. [Table 1] shows the characteristics and clinical experience of the 208 pathologists completing Phase I. Approximately half (48%) reported using the digital format in their professional work, mostly during conferences and teaching. While most (93%) pathologists reported confidence when interpreting breast pathology, 55% reported that breast pathology is challenging, and 44% reported that breast pathology makes them more nervous than other pathology types.
|Table 1: Characteristics of the 208 participating pathologists shown aggregated and by Phase I random assignment to traditional glass or digital whole slide imaging interpretation|
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Pathologists' confidence by interpretive format
Phase I results include 6,900 interpretations in glass slide format and 5,580 in digital format. When comparing glass slide versus digital format, pathologists reported similar rates of confidence (81.7% vs. 78.6%, P = 0.22) and percentage of interpretations marked as borderline between two diagnoses (26.1% vs. 24.6%, P = 0.35). However, glass slide interpretations were less likely than digital interpretations to be rated as challenging cases (30.0% vs. 38.5%, P = 0.003), and pathologists were less likely to desire a second opinion on glass than on digital interpretations (35.5% vs. 42.5%, P = 0.03).
Accuracy by format
Pathologists' accuracy within each diagnostic category was 3–5% higher for pathologists interpreting glass slides compared to those assigned to digital format: benign without atypia (glass: 87%, digital: 82%; P < 0.01); atypia (glass: 48%, digital: 43%; P = 0.08); DCIS (glass: 84%, digital: 79%; P < 0.01); and invasive carcinoma (glass: 96%, digital: 93%; P = 0.04) [Table 2] and [Figure 2]. Similar trends occurred when compared to the reference standard established by experts using the digital format, though the differences were slightly smaller, ranging from 2% to 3% [Appendix 2 [Additional file 3]].
|Table 2: Pathologists' accuracy by interpretive format (Phase I interpretations compared with the consensus panel reference interpretations)a|
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|Figure 2: Percent of Phase I under- and over-interpretations compared with the consensus reference diagnosis by pathologist interpretive format (glass slide or digital whole-slide imaging format)|
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The pathologist and case characteristics associated with accuracy using digital format (and lack thereof) were consistent with those previously observed in the interpretation of glass format [Appendix 3 [Additional file 4]]. For example, pathologists reporting higher breast interpretation case volume had higher accuracy in both interpretive formats, and accuracy was not influenced by patient age or breast biopsy type. Biopsy interpretations from women with dense breast tissue on prior mammography also had lower accuracy in the digital format compared to low-density breast tissue, similar to findings in traditional glass.
Reproducibility (intraobserver agreement between Phase I and Phase II)
Pathologists (n = 172) who completed interpretations in both phases on the same cases provided a total of 20,640 individual case assessments. Intraobserver agreement between interpretations of the same case (Phase I vs. Phase II) by diagnostic category and interpretive format is shown in [Figure 3] and [Appendix 4 [Additional file 5]]. The overall intraobserver agreement was highest when glass format was used in both phases at 79% (95%CI: 77%–81%). When the interpretive format changed between phases, the intraobserver agreement was slightly lower at 77% (95%CI: 75%–78%) but not statistically significantly different from the findings noted when the glass format was used in both phases (P = 0.08). A statistically significant difference, however, was noted when the glass format was used in both phases versus when the digital format was used in both phases, where the overall intraobserver agreement was 73% (95%CI: 71%–76%; P < 0.001). While pathologists' reproducibility was high for cases of invasive breast carcinoma, regardless of which format was used in the two phases or whether the format changed (93%–97%), it was low for cases in the middle categories such as atypia (56%–62%), regardless of interpretive format.
|Figure 3: Reproducibility of interpretations: Intraobserver agreement of participants' interpretations of the same case in Phase I and Phase II by diagnostic format used by the participant for interpretation in both phases. Data shown by the reference diagnosis of the case (n = 172 pathologists with a total of 20,640 individual case assessments) P-values correspond to comparrisons with intraobserver aggrement of pathologists who read glass slides in both phases|
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Evaluation for a learning curve among pathologists in the digital format
No learning curve was observed over the sixty cases interpreted digitally in Phase I (P = 0.85). There was also no difference in the accuracy between Phase II and Phase I among pathologists randomized to the digital format in both phases (P = 0.90). This was also true for pathologists randomized to the glass slide format in both phases (P = 0.35).
Predictive values of digital format compared with glass slide interpretations
The estimated numbers of cases under- and over-interpreted in the U.S. (i.e., that would be reclassified to a different diagnostic category by the reference consensus panel review) is shown in [Figure 4] by interpretive format and diagnostic category of the initial interpretation [Appendix 5 [Additional file 6]]. The predictive values for cases initially interpreted as invasive breast carcinoma are similar regardless of interpretive format. For example, a slide interpreted digitally as invasive carcinoma was 97.2% (95%CI: 95.6%–98.6%) likely to be confirmed as invasive carcinoma by our expert reference panel using the original glass slide. This is comparable to the previously reported predictive value when the initial interpretation was obtained by glass slide of 97.7% (95%CI: 96.5%–98.7%). Similarly, interpretations of benign without atypia were highly likely to be confirmed by the reference panel regardless of format (95.7% digital vs. 97.1% glass).
|Figure 4: Estimated numbers of breast biopsy cases that are under- and over-interpreted in the U.S. Results are shown for the number of cases that would be reclassified to a more (blue) or less (green) severe diagnostic category by the reference consensus panel diagnosis. Results pertain to women aged 50–59 years with recent screening mammograms in the U.S. and assume their biopsies were interpreted by pathologists using either a glass slide or a digitized image (one slide per case and without second opinions)|
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Of note, the estimated predictive values were significantly lower for atypia and DCIS in the digital interpretation format compared with glass interpretations (Wald test: atypia P = 0.002; DCIS P = 0.007). While these predictive values were statistically significantly lower for interpretations obtained in the digital format, the predictive values of these challenging cases as previously reported are also low in the glass format. For example, the predictive values for an initial atypia interpretation in the U.S. being in agreement with a reference review were 27.8% in the digital format versus 37.8% glass format, and for DCIS cases, the values were 57.1% digital versus 69.6% glass.
Pathologists using the digital format spent more time interpreting than pathologists using glass slides, as measured by total requested CME hours. The percentage of pathologists who reported spending 20 hours participating in the study (the maximum allowed) was higher among those interpreting in the digital format in both phases versus those interpreting in the glass format in both phases (76% digital versus 51% glass, respectively; P = 0.01; Wilcoxon rank-sum test for difference).
| Conclusions|| |
To date, our study of 240 biopsy cases interpreted by >200 pathologists from across the U.S. is the largest randomized study comparing traditional glass microscopy and digital WSI. Our study highlights the many challenges we face as we move into the digital era in the design and analyses of quality assessment studies. In our study, predictive value estimates were nearly identical regardless of interpretive format at the extremes of the diagnostic spectrum (e.g., invasive cancer and benign tissue), suggesting digital WSI could be employed for the primary diagnosis for these extreme categories. However, the more challenging (and less common) atypia and DCIS diagnostic categories in the middle of the spectrum have lower reproducibility and accuracy in the digital interpretive format. It should be noted that reproducibility and accuracy are also lower for atypia and DCIS when using glass slides, but the effect is amplified using digital WSI. As the field of digital pathology moves forward, attention to inclusion of the full spectrum of cases in validation studies will be important.
While our study followed the digital imaging validation guidelines recommended by the College of American Pathologists, our design also exceeded their recommendations in a few notable ways. Our study design included randomly allocating pathologists to interpretive format, using a random selection process for identifying cases, including a Phase I glass to Phase II glass reproducibility study arm as a benchmark, and employing a 9-month wash-out period between phases to reduce recall bias when assessing reproducibility. We also compared pathologists' accuracy using a carefully defined expert consensus reference standard. Finally, the investigators have no associations with manufacturers of digital WSI instruments or viewing platforms except that one commercial manufacturer provided use of a scanner to digitally archive the glass slides.
It is possible that the slightly lower accuracy with digital WSI imaging that we noted can be corrected with experience. Among pathologists reporting prior experience using digital WSI, we noted a nonsignificant trend for higher accuracy of digital interpretations than for pathologists who reported no experience with WSI, even after accounting for the effects of other pathologist-level characteristics. However, participating pathologists had limited experience with the digital format as it is not currently approved for primary diagnostic use in the U.S. by the FDA. It may be too early to address whether experience with the digital format results in improved diagnostic accuracy.
In the digital format, pathologists were more likely to deem a case challenging and spent more time interpreting cases compared to pathologists using glass slides – circumstantial evidence suggesting that experience with the technology may be an issue. Technological improvements to image acquisition and standardized display systems, coupled with physician education and experience using digital WSI, may reduce performance gaps between the formats. While no learning curve was noted in performance during this study, gaining experience requires time, and sixty cases without an educational intervention may be inadequate. The absence of a learning curve has been noted by others, though an improvement in accuracy after completing an educational intervention was reported in one study.
Many areas of pathology are challenging and might benefit from digital technology. Pathologists are understandably concerned about the high level of difficulty of breast pathology  and the high risk for medical malpractice when a cancer diagnosis is a possibility. Pathologists are also likely to desire a second opinion to improve clinical care on breast cases more often than being required by existing laboratory policies. Digital technology could, therefore, be an important tool to facilitate second opinions on these challenging cases.
Pathologists interpret differently using traditional glass slide microscopy versus digital WSI format. Behind the microscope, small finger movements reposition the slide, and eye saccades scan the microscopic field; the remainder of the head and body are stationary. Digital viewing requires larger hand movements to pan and zoom and greater head and eye movements to scan all areas of the image. In addition, for pathologists wearing corrective lenses, particularly bifocals or variable focus lenses, constant corrections are needed to maintain focus. Implementation studies in Sweden suggest job-specific ergonomics may be improved by incorporating the digital format.
Special considerations in designing quality assessment studies
Technologic improvements in design and image quality are occurring quickly in this field. Going forward, proposed technical performance parameters and regulation of digital imaging have been outlined by the FDA and discussed by others.,, One potential limitation to this study is that each pathologist completed the histology evaluation remotely using their own microscope and computer, with no standardization. We do not have information on their workstation and monitor specifications or internet and bandwidth capabilities. The scanner we used is no longer commercially available, and scanner technology is rapidly updating. However, the digital whole slide images were acquired using a 40× objective lens and research staff carefully reviewed the digital scan image of each slide to avoid errors introduced during digital scanning and to assure quality.
In a randomized study design such as ours, other limiting factors apply equally to both glass and digital formats. For example, our study included one slide per case, assessment of performance in a testing situation instead of actual clinical setting, and a higher proportion of benign proliferative, atypia, and DCIS cases than usual clinical practice, as well as a relatively small number of invasive cancer cases. While these can be considered limitations, these limiting factors were equally present in the digital and the glass format testing.
Digital imaging technology has revolutionized medicine and is an important emerging adjunct to traditional light microscopy that might greatly aid the practice of pathology. We noted that diagnoses of invasive breast carcinoma are highly reproducible using both glass and digital formats. However, clinical practice includes a broad spectrum of cases, including those in the middle diagnostic categories, and these cases are often more challenging to diagnose even in the traditional glass slide format. As noted in this study, the more challenging high-risk and preinvasive lesions (atypia and DCIS) may have lower predictive value using a digital format compared with a glass slide format. We encourage future studies evaluating the effect(s) of the digital format on patient outcomes to include the full spectrum of cases and consider the randomized design features presented in our study.
The collection of cancer and vital status data was supported in part by several state public health departments and cancer registries throughout the U.S. For a full description of these sources, please see: http://www.breastscreening.cancer.gov/work/acknowledgement.html. The authors thank Ventana Medical Systems, Inc. (Roche Group) for iScan Coreo Au ™ whole slide imaging system use. HD View SL was used as the source code to build our digital viewer; see http://hdviewsl.codeplex.com/ for details. The authors also thank the participating pathologists.
Financial support and sponsorship
This study was supported by the National Cancer Institute (R01CA140560, R01CA172343, K05CA104699, U01CA86082, U01CA70013) and the NCI-funded Breast Cancer Surveillance Consortium (HHSN261201100031C).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]