title: Classification of fatty and dense breast parenchyma: comparison of automatic volumetric density measurement and radiologists' classification and their inter-observer variation.
abstract: BACKGROUND
  Automatically calculated breast density is a promising alternative to subjective BI-RADS density assessment. However, such software needs a cutoff value for density classification.
  
  
  OBJECTIVE
  To determine the volumetric density threshold which classifies fatty and dense breasts with highest accuracy compared to average BI-RADS density assessment, and to analyze radiologists' inter-observer variation.
  
  
  METHODS
  A total of 537 full field digital mammography examinations were randomly selected from a population based screening program. Five radiologists assessed density using the BI-RADS density scale, where BI-RADS I-II were classified as fatty and III-IV as dense. A commercially available software (Quantra) calculated volumetric breast density. We calculated the cutoff (threshold) values in volumetric density that yielded highest accuracy compared to median and individual radiologists' classification. Inter-observer variation was analyzed using the kappa statistic.
  
  
  RESULTS
  The threshold that best matched the median radiologists' classification was 10%, which resulted in 87% accuracy. Thresholds that best matched individual radiologist's classification had a range of 8-15%. A total of 191 (35.6 %) cases were scored both dense and fatty by at least one radiologist. Fourteen (2.6 %) cases were unanimously scored by the radiologists, yet differently using automatic assessment. The agreement (kappa) between reader's median classification and individual radiologists was 0.624 to 0.902, and agreement between median classification and Quantra was 0.731.
  
  
  CONCLUSIONS
  The optimal volumetric threshold of 10% using automatic assessment would classify breast parenchyma as fatty or dense with substantial accuracy and consistency compared to radiologists' BI-RADS categorization, which suffers from high inter-observer variation.
authors.affiliation: The Intervention Centre, Oslo University Hospital, Oslo, Norway Institute of Clinical Medicine, University of Oslo, Oslo, Norway Bjorn.Helge.Osteras@ous-hf.no.
authors.forename: Bjørn Helge
authors.initials: BH
authors.lastname: Østerås
authors.affiliation: The Intervention Centre, Oslo University Hospital, Oslo, Norway Institute of Physics, University of Oslo, Oslo, Norway.
authors.forename: Anne Catrine T
authors.initials: AC
authors.lastname: Martinsen
authors.affiliation: Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
authors.forename: Siri Helene B
authors.initials: SH
authors.lastname: Brandal
authors.affiliation: Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
authors.forename: Khalida Nasreen
authors.initials: KN
authors.lastname: Chaudhry
authors.affiliation: Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
authors.forename: Ellen
authors.initials: E
authors.lastname: Eben
authors.affiliation: Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
authors.forename: Unni
authors.initials: U
authors.lastname: Haakenaasen
authors.affiliation: Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway.
authors.forename: Ragnhild Sørum
authors.initials: RS
authors.lastname: Falk
authors.affiliation: Institute of Clinical Medicine, University of Oslo, Oslo, Norway Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
authors.forename: Per
authors.initials: P
authors.lastname: Skaane
mesh_terms: D000071060:Breast Density; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology; D002983:Clinical Competence; D005260:Female; D006801:Humans; D008327:Mammography; D015588:Observer Variation; D011857:Radiographic Image Interpretation, Computer-Assisted; D000072177:Radiologists; D012984:Software
keywords: BI-RADS density categories; Breast density; automated volumetric breast density measurements; breast cancer screening; breast density classification; digital mammography