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Appropriateness Criteria

Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 1 0 0 0 0 4 2 10
References Study Quality
13 (37249433) 3
12 (30107542) Good
11 (31084476) 4
10 (35352019) Good
9 (30816931) 3
4 (2858707) 3
3 (31063080) 3
2 (-3100780) 4
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 4 5 4 0 0 1 0 0
References Study Quality
20 (32903054) 4
19 (33032820) Good
18 (36999589) 4
17 (36719288) Good
7 (37150275) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 8 2 6 0 0 1 0 1 0
References Study Quality
14 (27097789) 3
15 (36108478) 4
MRI breast without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 7 4 4 0 1 1 0 1 0
References Study Quality
16 (28221097) 1
MRI breast without and with IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 3 2 0 2 0 1 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 2 0 0 0 0 0 0 1
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 0 0 1 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 17 0 0 0 0 0 0 0 1
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 17 0 0 0 0 0 0 0 1
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 1 0 16
References Study Quality
20 (32903054) 4
17 (36719288) Good
13 (37249433) 3
12 (30107542) Good
11 (31084476) 4
10 (35352019) Good
9 (30816931) 3
4 (2858707) 3
3 (31063080) 3
2 (-3100780) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 11 4 1 0 0
References Study Quality
35 (30316869) 1
34 (26547101) 2
33 (34406400) 2
20 (32903054) 4
19 (33032820) Good
18 (36999589) 4
17 (36719288) Good
7 (37150275) 4
MRI breast without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 13 2 2 0 0
References Study Quality
17 (36719288) Good
16 (28221097) 1
MRI breast without and with IV contrast abbreviated May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 12 2 2 0 0
References Study Quality
29 (32931396) 2
28 (32096852) 1
27 (28749202) 4
26 (30887736) 4
25 (26152500) 2
24 (24958821) 2
23 (37581498) 3
19 (33032820) Good
Mammography with IV contrast Usually not appropriate Strong ☢☢ 0.1-1mSv 2 2 8 4 5 0 0 0 0 0 0
References Study Quality
22 (31453765) 2
21 (30240292) 2
15 (36108478) 4
14 (27097789) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 3 0 0 0 1 0 0 0
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 2 0 0 0 0 1 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 2 1 1 1 0 0 1 0
References Study Quality
32 (27186635) 3
31 (25615744) 1
30 (34887334) 4
7 (37150275) 4
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 1 0 0 0 0 1 15
References Study Quality
20 (32903054) 4
17 (36719288) Good
13 (37249433) 3
12 (30107542) Good
11 (31084476) 4
10 (35352019) Good
9 (30816931) 3
4 (2858707) 3
3 (31063080) 3
2 (-3100780) 4
MRI breast without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 2 8 5 2
References Study Quality
38 (18389253) 4
37 (33724062) 3
36 (31774954) Good
MRI breast without and with IV contrast abbreviated Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 1 10 4 2
References Study Quality
29 (32931396) 2
28 (32096852) 1
27 (28749202) 4
26 (30887736) 4
25 (26152500) 2
24 (24958821) 2
23 (37581498) 3
19 (33032820) Good
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 8 4 4 0 0
References Study Quality
35 (30316869) 1
34 (26547101) 2
33 (34406400) 2
20 (32903054) 4
19 (33032820) Good
18 (36999589) 4
17 (36719288) Good
7 (37150275) 4
Mammography with IV contrast Usually not appropriate Strong ☢☢ 0.1-1mSv 2 2 6 3 6 1 1 0 0 0 0
References Study Quality
22 (31453765) 2
21 (30240292) 2
15 (36108478) 4
14 (27097789) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 0 1 0 0
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 2 0 0 0 0 1 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 0 0 0 0 1 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 3 1 1 0 0 0 1 0
References Study Quality
7 (37150275) 4
32 (27186635) 3
31 (25615744) 1
30 (34887334) 4
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 1 0 0 0 0 4 3 9
References Study Quality
13 (37249433) 3
12 (30107542) Good
11 (31084476) 4
10 (35352019) Good
9 (30816931) 3
4 (2858707) 3
3 (31063080) 3
2 (-3100780) 4
MRI breast without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 0 1 9 0 2
References Study Quality
3 (31063080) 3
39 (35783682) 4
MRI breast without and with IV contrast abbreviated May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 6 8 1 2 0 0
References Study Quality
24 (24958821) 2
28 (32096852) 1
27 (28749202) 4
26 (30887736) 4
25 (26152500) 2
23 (37581498) 3
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 3 5 1 2 0 1 0 1
References Study Quality
20 (32903054) 4
19 (33032820) Good
18 (36999589) 4
17 (36719288) Good
7 (37150275) 4
Mammography with IV contrast Usually not appropriate Strong ☢☢ 0.1-1mSv 3 3 5 2 5 1 2 2 0 0 0
References Study Quality
14 (27097789) 3
22 (31453765) 2
21 (30240292) 2
15 (36108478) 4
41 (33787291) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 1 0 0 0
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 0 1 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 0 0 0 1 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 17 0 0 0 0 0 0 1 0
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 1 16
References Study Quality
20 (32903054) 4
17 (36719288) Good
13 (37249433) 3
12 (30107542) Good
11 (31084476) 4
10 (35352019) Good
9 (30816931) 3
4 (2858707) 3
3 (31063080) 3
2 (-3100780) 4
MRI breast without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 10 4 2
References Study Quality
17 (36719288) Good
7 (37150275) 4
3 (31063080) 3
MRI breast without and with IV contrast abbreviated Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 10 4 2
References Study Quality
29 (32931396) 2
28 (32096852) 1
27 (28749202) 4
26 (30887736) 4
25 (26152500) 2
24 (24958821) 2
23 (37581498) 3
19 (33032820) Good
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 13 2 2 0 0
References Study Quality
35 (30316869) 1
34 (26547101) 2
33 (34406400) 2
20 (32903054) 4
19 (33032820) Good
18 (36999589) 4
17 (36719288) Good
7 (37150275) 4
Mammography with IV contrast May be appropriate Strong ☢☢ 0.1-1mSv 5 5 0 0 0 0 12 4 1 0 0
References Study Quality
22 (31453765) 2
21 (30240292) 2
15 (36108478) 4
14 (27097789) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 2 0 1 0 0 0 0 0
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 2 0 1 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 0 0 1 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 1 1 2 0 0 1 0 0
References Study Quality
32 (27186635) 3
31 (25615744) 1
30 (34887334) 4
7 (37150275) 4
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 2 15
References Study Quality
20 (32903054) 4
17 (36719288) Good
13 (37249433) 3
12 (30107542) Good
11 (31084476) 4
10 (35352019) Good
9 (30816931) 3
4 (2858707) 3
3 (31063080) 3
2 (-3100780) 4
MRI breast without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 2 0 3 0 6 4 3
References Study Quality
38 (18389253) 4
37 (33724062) 3
36 (31774954) Good
MRI breast without and with IV contrast abbreviated Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 11 2 3
References Study Quality
29 (32931396) 2
28 (32096852) 1
26 (30887736) 4
25 (26152500) 2
24 (24958821) 2
23 (37581498) 3
19 (33032820) Good
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 14 2 1 0 0
References Study Quality
35 (30316869) 1
34 (26547101) 2
33 (34406400) 2
20 (32903054) 4
19 (33032820) Good
18 (36999589) 4
17 (36719288) Good
7 (37150275) 4
Mammography with IV contrast May be appropriate Strong ☢☢ 0.1-1mSv 6 6 0 0 0 0 7 9 1 0 0
References Study Quality
41 (33787291) 3
22 (31453765) 2
21 (30240292) 2
15 (36108478) 4
14 (27097789) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 1 0 0 0 0 0
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 1 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 17 0 0 0 1 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 0 2 2 0 0 1 0 0
References Study Quality
32 (27186635) 3
31 (25615744) 1
30 (34887334) 4
7 (37150275) 4
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 1 16
References Study Quality
20 (32903054) 4
17 (36719288) Good
13 (37249433) 3
12 (30107542) Good
11 (31084476) 4
10 (35352019) Good
9 (30816931) 3
4 (2858707) 3
3 (31063080) 3
2 (-3100780) 4
MRI breast without and with IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 9 9 1 1 0 0 0 0 3 3 10
References Study Quality
3 (31063080) 3
5 (30255244) 4
42 (21139507) 1
MRI breast without and with IV contrast abbreviated Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 6 1 2 6 2
References Study Quality
26 (30887736) 4
25 (26152500) 2
24 (24958821) 2
23 (37581498) 3
19 (33032820) Good
43 (26521970) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 10 0 5 2 0
References Study Quality
35 (30316869) 1
34 (26547101) 2
33 (34406400) 2
20 (32903054) 4
19 (33032820) Good
18 (36999589) 4
17 (36719288) Good
7 (37150275) 4
Mammography with IV contrast May be appropriate Strong ☢☢ 0.1-1mSv 5 5 0 0 0 0 13 3 1 0 0
References Study Quality
23 (37581498) 3
22 (31453765) 2
21 (30240292) 2
15 (36108478) 4
14 (27097789) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 1 1 0 0 0 0 0
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 1 1 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 1 0 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 0 3 1 1 0 1 0 0
References Study Quality
32 (27186635) 3
31 (25615744) 1
30 (34887334) 4
7 (37150275) 4
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.