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Appropriateness Criteria

Variant 1: Adult female. Breast cancer screening. Average risk.
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 Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 1 18
References Study Quality
14 (25058084) 3
15 (24918774) 3
16 (23901124) 3
19 (25313245) 2
21 (23297332) 1
34 (33650900) 3
33 (33141657) 3
32 (21257850) 4
31 (25415718) 4
30 (33706172) Good
29 (28516226) Good
27 (16775176) Good
26 (29571797) 2
25 (32721031) 3
24 (28083822) 1
23 (25599513) 2
22 (30777808) 3
20 (29869961) 1
18 (30107542) Good
17 (31078459) 1
8 (34154984) 4
6 (-3196037) 4
5 (26501536) 4
28 (20868890) 4
35 (25413699) Inadequate
Mammography screening Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 4 15
References Study Quality
1 (21712474) 1
7 (26757170) 4
41 (26204111) 4
38 (28648873) 4
40 (33223001) 4
39 (28411671) 4
37 (27754936) 4
36 (29267146) 4
35 (25413699) Inadequate
34 (33650900) 3
33 (33141657) 3
32 (21257850) 4
31 (25415718) 4
27 (16775176) Good
26 (29571797) 2
8 (34154984) 4
6 (-3196037) 4
5 (26501536) 4
2 (24450666) 3
3 (37150275) 4
28 (20868890) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 2 3 10 5 0 0 1
References Study Quality
49 (22723501) 2
10 (34794600) 4
56 (24951614) 3
55 (34406400) 2
54 (29736009) Good
53 (33434108) 3
52 (34134531) 4
51 (27501888) 1
50 (30316869) 1
40 (33223001) 4
27 (16775176) Good
26 (29571797) 2
MRI breast without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 0 0 3 4 12 2 0 0 0
References Study Quality
10 (34794600) 4
44 (3528677) 4
43 (31774954) Good
42 (28221097) 1
28 (20868890) 4
MRI breast without and with IV contrast abbreviated May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 0 0 2 4 13 2 0 0 0
References Study Quality
10 (34794600) 4
45 (32096852) 1
28 (20868890) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 3 3 8 1 6 0 1 0 0
References Study Quality
10 (34794600) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 1 2 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 19 0 1 2 0 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 1 5 3 0 0 1 0 0
References Study Quality
48 (32524221) 2
47 (31880677) 4
46 (27186635) 3
40 (33223001) 4
Variant 2: Adult female. Breast cancer screening. Intermediate risk.
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 Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 2 2 18
References Study Quality
14 (25058084) 3
15 (24918774) 3
16 (23901124) 3
19 (25313245) 2
21 (23297332) 1
38 (28648873) 4
40 (33223001) 4
35 (25413699) Inadequate
34 (33650900) 3
33 (33141657) 3
32 (21257850) 4
31 (25415718) 4
30 (33706172) Good
29 (28516226) Good
27 (16775176) Good
26 (29571797) 2
25 (32721031) 3
24 (28083822) 1
23 (25599513) 2
22 (30777808) 3
20 (29869961) 1
18 (30107542) Good
17 (31078459) 1
8 (34154984) 4
6 (-3196037) 4
5 (26501536) 4
3 (37150275) 4
Mammography screening Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 3 16
References Study Quality
38 (28648873) 4
41 (26204111) 4
40 (33223001) 4
39 (28411671) 4
37 (27754936) 4
36 (29267146) 4
35 (25413699) Inadequate
34 (33650900) 3
33 (33141657) 3
32 (21257850) 4
31 (25415718) 4
27 (16775176) Good
26 (29571797) 2
8 (34154984) 4
7 (26757170) 4
5 (26501536) 4
2 (24450666) 3
1 (21712474) 1
6 (-3196037) 4
3 (37150275) 4
28 (20868890) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 13 5 1 0 0
References Study Quality
61 (22474203) 1
76 (30098212) 3
66 (28655029) 3
55 (34406400) 2
54 (29736009) Good
53 (33434108) 3
52 (34134531) 4
51 (27501888) 1
50 (30316869) 1
49 (22723501) 2
40 (33223001) 4
27 (16775176) Good
26 (29571797) 2
10 (34794600) 4
Mammography with IV contrast May be appropriate Strong ☢☢ 0.1-1mSv 5 5 0 0 0 2 14 4 1 0 0
References Study Quality
60 (31453765) 2
59 (30240292) 2
58 (31092346) 2
57 (33787291) 3
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 8 11 2 0 0
References Study Quality
69 (27097237) 4
68 (31221620) 3
67 (32303988) Inadequate
66 (28655029) 3
65 (31063080) 3
64 (19884532) 1
63 (25794083) 4
62 (20177029) 1
61 (22474203) 1
70 (24934793) 3
MRI breast without and with IV contrast abbreviated May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 8 12 1 0 0
References Study Quality
45 (32096852) 1
53 (33434108) 3
75 (28506511) 4
74 (25454099) 2
73 (31206889) 3
72 (33620293) 3
71 (24958821) 2
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 2 0 1 0 0 0 0
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 2 0 1 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 9 1 5 3 2 0 2 0 0
References Study Quality
40 (33223001) 4
47 (31880677) 4
48 (32524221) 2
Variant 3: Adult female. Breast cancer screening. High risk.
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 Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 2 1 19
References Study Quality
14 (25058084) 3
15 (24918774) 3
16 (23901124) 3
19 (25313245) 2
21 (23297332) 1
80 (27444927) 4
79 (26908327) Inadequate
40 (33223001) 4
35 (25413699) Inadequate
34 (33650900) 3
33 (33141657) 3
32 (21257850) 4
31 (25415718) 4
30 (33706172) Good
29 (28516226) Good
27 (16775176) Good
26 (29571797) 2
25 (32721031) 3
24 (28083822) 1
23 (25599513) 2
22 (30777808) 3
20 (29869961) 1
18 (30107542) Good
17 (31078459) 1
8 (34154984) 4
6 (-3196037) 4
5 (26501536) 4
3 (37150275) 4
Mammography screening Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 2 17
References Study Quality
38 (28648873) 4
81 (28886475) Inadequate
80 (27444927) 4
79 (26908327) Inadequate
41 (26204111) 4
40 (33223001) 4
39 (28411671) 4
37 (27754936) 4
36 (29267146) 4
35 (25413699) Inadequate
34 (33650900) 3
33 (33141657) 3
32 (21257850) 4
31 (25415718) 4
27 (16775176) Good
26 (29571797) 2
8 (34154984) 4
7 (26757170) 4
5 (26501536) 4
2 (24450666) 3
1 (21712474) 1
6 (-3196037) 4
3 (37150275) 4
MRI breast without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 1 4 1 15
References Study Quality
61 (22474203) 1
62 (20177029) 1
64 (19884532) 1
4 (17392385) 4
81 (28886475) Inadequate
70 (24934793) 3
69 (27097237) 4
68 (31221620) 3
67 (32303988) Inadequate
66 (28655029) 3
65 (31063080) 3
63 (25794083) 4
40 (33223001) 4
3 (37150275) 4
MRI breast without and with IV contrast abbreviated Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 4 5 10 1 1
References Study Quality
4 (17392385) 4
75 (28506511) 4
74 (25454099) 2
73 (31206889) 3
72 (33620293) 3
3 (37150275) 4
US breast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 3 1 9 3 3 0 0
References Study Quality
61 (22474203) 1
82 (16293877) 2
76 (30098212) 3
66 (28655029) 3
64 (19884532) 1
63 (25794083) 4
62 (20177029) 1
10 (34794600) 4
Mammography with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 0 1 2 1 3 6 7 0 1
References Study Quality
60 (31453765) 2
59 (30240292) 2
58 (31092346) 2
57 (33787291) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 2 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 19 0 2 0 0 1 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 11 1 4 1 3 1 0 0 1
References Study Quality
40 (33223001) 4
47 (31880677) 4
48 (32524221) 2
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.