Reporting and Perceptions of Breast Arterial Calcification on Mammography: A Survey of ACR Radiologists

Published:February 17, 2021DOI:

      Rationale and Objectives

      The ACR Breast Commission conducted a member survey to evaluate current practices of reporting breast arterial calcification (BAC) on mammography and to determine perceptions about the value of BAC communication and follow-up recommendations among radiologists.

      Materials and Methods

      In September 2020, an 18-item online survey was emailed to radiologist members of the American College of Radiology (ACR). Questions included radiologist demographics, current BAC reporting practices, follow-up recommendations, and perceptions about BAC. Five-point Likert scales were used and multivariate analysis was performed.


      Of 598 completed survey responses, up to 87% (522/598) of ACR radiologist members include BAC in mammogram reports. However, only 41% (212/522) of respondents report BAC ‘always’ or ‘most of the time’. Radiologist factors significantly associated with BAC reporting include years in practice and fellowship training with those in practice longer more likely to report BAC (OR 1.10, 95% CI, [1.01-1.20], p = 0.023) and those with fellowship training less likely to report BAC (OR 0.63, 95% CI, [0.42-0.94], p = 0.024). When BAC is reported, 69% (360/522) simply indicate the presence of BAC, 23% (121/522) provide a subjective grading of BAC burden, and 1% (6/522) calculate a BAC score. Among the radiologists reporting BAC, 58% (301/522) make no subsequent recommendations, while the remainder recommend primary care follow-up (39%; 204/522), cardiology evaluation (13%; 68/522), and/or coronary calcium scoring CT (11%; 59/522). Overall, there was agreement from 66% (392/598) of respondents that BAC is a cardiovascular risk factor. However, there was no consensus on whether patients and/or providers should be informed about BAC or whether reporting of BAC should become a standardized practice in breast imaging. Older and more experienced radiologists are more likely to agree that BAC is a cardiovascular risk factor (p = 0.022), providers should be informed about BAC (p = 0.002 and 0.006), BAC reporting should be a standardized practice (p = 0.004 and 0.001), and feel more comfortable informing patients about BAC (p = 0.001 and 0.003).


      Radiologists’ reporting practices and perceptions regarding BAC are not homogeneous. Although many radiologists report BAC to varying degrees, it is not routinely reported or recommended for follow-up in mammogram reports. Experienced radiologists are more likely to include and value BAC in their breast imaging practice.

      Key Words

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        • DeSantis C.E.
        • Ma J
        • Gaudet MM
        • et al.
        Breast cancer statistics, 2019.
        CA Cancer J Clin. 2019; 69: 438-451
      1. Cancer Facts & Figures; 2020.
        2020 (Available from:) (Accessed September 15, 2020)
        • Dunbar S.B.
        • OA Khavjou
        • Bakas T
        • et al.
        Projected costs of informal caregiving for cardiovascular disease: 2015 to 2035: a policy statement from the American Heart Association.
        Circulation. 2018; 137: e558-e577
        • McClelland R.L.
        • Jorgensen NW
        • Budoff M
        • et al.
        10-Year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) with validation in the HNR (Heinz Nixdorf Recall) study and the DHS (Dallas Heart Study).
        J Am Coll Cardiol. 2015; 66: 1643-1653
        • Wilmot K.A.
        • O'Flaherty M
        • Capewell S
        • et al.
        Coronary heart disease mortality declines in the United States From 1979 Through 2011: evidence for stagnation in young adults, especially women.
        Circulation. 2015; 132: 997-1002
        • Mozaffarian D.
        • Benjamin EJ
        • Go AS
        • et al.
        Heart disease and stroke statistics–2015 update: a report from the American Heart Association.
        Circulation. 2015; 131: e29-322
        • Roger V.L.
        • Go AS
        • Lloyd-Jones DM
        • et al.
        Heart disease and stroke statistics–2012 update: a report from the American Heart Association.
        Circulation. 2012; 125: e2-e220
        • Michos E.D.
        • Nasir K
        • Braunstein JB
        • et al.
        Framingham risk equation underestimates subclinical atherosclerosis risk in asymptomatic women.
        Atherosclerosis. 2006; 184: 201-206
        • Amin N.P.
        • Martin SS
        • Blaha M
        • et al.
        Headed in the right direction but at risk for miscalculation: a critical appraisal of the 2013 ACC/AHA risk assessment guidelines.
        J Am Coll Cardiol. 2014; 63: 2789-2794
        • Cook N.R.
        • Ridker P.M.
        Further insight into the cardiovascular risk calculator: the roles of statins, revascularizations, and underascertainment in the Women's Health Study.
        JAMA Intern Med. 2014; 174: 1964-1971
        • Muntner P.
        • Colantonio LD
        • Cushman M
        • et al.
        Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations.
        JAMA. 2014; 311: 1406-1415
        • DeFilippis A.P.
        • Young R.
        • Blaha M.J.
        Calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort.
        Ann Intern Med. 2015; 163: 68-69
        • Ridker P.M.
        • Cook N.R.
        The pooled cohort equations 3 years on: building a stronger foundation.
        Circulation. 2016; 134: 1789-1791
        • Agrawal S.
        • Van Eyk J
        • Sobhani K
        • et al.
        Sex, Myocardial infarction, and the failure of risk scores in women.
        J Womens Health (Larchmt). 2015; 24: 859-861
        • Bui Q.M.
        • Daniels L.B.
        A review of the role of breast arterial calcification for cardiovascular risk stratification in women.
        Circulation. 2019; 139: 1094-1101
        • Suh J.W.
        • Yun B.
        Breast arterial calcification: a potential surrogate marker for cardiovascular disease.
        J Cardiovasc Imaging. 2018; 26: 125-134
        • Yoon Y.E.
        • Kim KM
        • Han JS
        • et al.
        Prediction of subclinical coronary artery disease with breast arterial calcification and low bone mass in asymptomatic women: registry for the women health cohort for the BBC study.
        JACC Cardiovasc Imaging. 2019; 12: 1202-1211
        • Yoon Y.E.
        • Kim KM
        • Lee W
        • et al.
        Breast Arterial calcification is associated with the progression of coronary atherosclerosis in asymptomatic women: a preliminary retrospective cohort study.
        Sci Rep. 2020; 10: 2755
        • Margolies L.
        • Salvatore M
        • Hecht HS
        • et al.
        Digital mammography and screening for coronary artery disease.
        JACC Cardiovasc Imaging. 2016; 9: 350-360
        • Lee S.C.
        • Phillips M
        • Bellinge J
        • et al.
        Is breast arterial calcification associated with coronary artery disease?-A systematic review and meta-analysis.
        PLoS One. 2020; 15e0236598
        • Nasir K.
        • McEvoy J.W.
        recognizing breast arterial calcification as atherosclerotic CVD risk equivalent: from evidence to action.
        JACC Cardiovasc Imaging. 2016; 9: 361-363
        • Polonsky T.S.
        • Greenland P.
        Breast arterial calcification: expanding the reach of cardiovascular prevention.
        Circulation. 2017; 135: 499-501
        • Mantas D.
        • Markopoulos C.
        Screening mammography: Usefulness beyond early detection of breast cancer.
        Atherosclerosis. 2016; 248: 1
        • D'Orsi CJ
        • Sickles E.M.E.M.E.
        ACRBI-RADS® Atlas Breast Imaging Reporting and Data System.
        American College of Radiology, Reston, VA2013
        • Harris P.A.
        • Taylor R
        • Thielke R
        • et al.
        Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Harris P.A.
        • Taylor R
        • Minor BL
        • et al.
        The REDCap consortium: Building an international community of software platform partners.
        J Biomed Inform. 2019; 95103208
        • Trimboli R.M.
        • Capra D
        • Codari M
        • et al.
        Breast arterial calcifications as a biomarker of cardiovascular risk: radiologists' awareness, reporting, and action. A survey among the EUSOBI members.
        Eur Radiol. 2020;
        • Volgman A.S.
        • Palaniappan LS
        • Aggarwal NT
        • et al.
        Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association.
        Circulation. 2018; 138: e1-e34
        • Wall H.K.
        • Ritchey MD
        • Gillespie C
        • et al.
        Vital Signs: Prevalence of key cardiovascular disease risk factors for million hearts 2022 - United States, 2011-2016.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 983-991
        • Iribarren C.
        • Sanchez G
        • Husson G
        • et al.
        MultIethNic study of breast arterial calcium gradation and cardiovascular disease: cohort recruitment and baseline characteristics.
        Ann Epidemiol. 2018; 28 (e12): 41-47
        • Dehkordy S.F.
        • Carlos R.C.
        Dense breast legislation in the United States: state of the states.
        J Am Coll Radiol. 2013; 10: 899-902
        • Cappello N.M.
        Decade of 'normal' mammography reports–the happygram.
        J Am Coll Radiol. 2013; 10: 903-908
        • Kaplan S.S.
        Clinical utility of bilateral whole-breast US in the evaluation of women with dense breast tissue.
        Radiology. 2001; 221: 641-649
        • Maimone S.
        • McDonough M.D.
        • Hines S.L.
        Breast density reporting laws and supplemental screening-a survey of referring providers' experiences and understanding.
        Curr Probl Diagn Radiol. 2017; 46: 105-109
        • Maimone S.
        • McDonough M.
        Dense breast notification and supplemental screening: a survey of current strategies and sentiments.
        Breast J. 2017; 23: 193-199
        • Margolies L.R.
        • Yip R
        • Hwang E
        • et al.
        Breast arterial calcification in the mammogram report: the patient perspective.
        AJR Am J Roentgenol. 2019; 212: 209-214
        • Frieden T.R.
        • Berwick D.M.
        The "Million Hearts" initiative–preventing heart attacks and strokes.
        N Engl J Med. 2011; 365: e27
        • Benjamin E.J.
        • Virani SS
        • Callaway CW
        • et al.
        Heart Disease and stroke statistics-2018 update: a report from the American Heart Association.
        Circulation. 2018; 137: e67-e492
        • Centers for Disease, C. and Prevention
        Vital signs: avoidable deaths from heart disease, stroke, and hypertensive disease - United States, 2001-2010.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 721-727
        • Abuful A.
        • Gidron Y.
        • Henkin Y.
        Physicians' attitudes toward preventive therapy for coronary artery disease: is there a gender bias?.
        Clin Cardiol. 2005; 28: 389-393
        • Mosca L.
        • Linfante AH
        • Benjami EJ
        • et al.
        National study of physician awareness and adherence to cardiovascular disease prevention guidelines.
        Circulation. 2005; 111: 499-510
        • Yusuf S.
        • Hawken S
        • Ounpuu S
        • et al.
        Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 937-952
        • Singh H.
        • Spitzmueller C
        • Petersen NJ
        • et al.
        Primary care practitioners' views on test result management in EHR-enabled health systems: a national survey.
        J Am Med Inform Assoc. 2013; 20: 727-735
        • Trimboli R.M.
        • Codari M
        • Guazzi M
        • et al.
        Screening mammography beyond breast cancer: breast arterial calcifications as a sex-specific biomarker of cardiovascular risk.
        Eur J Radiol. 2019; 119108636
        • Spayne M.C.
        • Gard CC
        • Skelly J
        • et al.
        Reproducibility of BI-RADS breast density measures among community radiologists: a prospective cohort study.
        Breast J. 2012; 18: 326-333
        • Alonzo-Proulx O.
        • Mawdsley GE
        • Patrie JT
        • et al.
        Reliability of automated breast density measurements.
        Radiology. 2015; 275: 366-376