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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 0 0 0
References Study Quality
17 (25058084) 3
18 (24918774) 3
19 (23901124) 3
22 (25313245) 2
24 (23297332) 1
32 (28516226) Good
23 (29869961) 1
29 (29571797) 2
27 (28083822) 1
5 (26501536) 4
26 (25599513) 2
38 (25413699) Inadequate
34 (25415718) 4
21 (30107542) Good
35 (21257850) 4
20 (31078459) 1
25 (30777808) 3
36 (33141657) 3
28 (32721031) 3
37 (33650900) 3
11 (34154984) 4
30 (16775176) Good
33 (33706172) Good
6 (-3196037) 4
31 (20868890) 4
10 (38687505) 4
9 (38687503) 4
3 (37150275) 4
Mammography screening Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
1 (21712474) 1
7 (26757170) 4
44 (26204111) 4
41 (28648873) 4
2 (24450666) 3
29 (29571797) 2
39 (29267146) 4
42 (28411671) 4
40 (27754936) 4
5 (26501536) 4
38 (25413699) Inadequate
34 (25415718) 4
35 (21257850) 4
36 (33141657) 3
43 (33223001) 4
37 (33650900) 3
11 (34154984) 4
30 (16775176) Good
6 (-3196037) 4
3 (37150275) 4
31 (20868890) 4
10 (38687505) 4
9 (38687503) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
52 (22723501) 2
57 (29736009) Good
29 (29571797) 2
54 (27501888) 1
59 (24951614) 3
13 (34794600) 4
56 (33434108) 3
43 (33223001) 4
58 (34406400) 2
55 (34134531) 4
53 (30316869) 1
30 (16775176) Good
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
45 (28221097) 1
46 (31774954) Good
13 (34794600) 4
47 (3528677) 4
31 (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 0 0 0 0 0 0 0
References Study Quality
48 (32096852) 1
13 (34794600) 4
31 (20868890) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 0 0 0 0 0 0 0 0 0
References Study Quality
13 (34794600) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 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 0 0 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
49 (27186635) 3
50 (31880677) 4
51 (32524221) 2
43 (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 0 0 0
References Study Quality
17 (25058084) 3
18 (24918774) 3
19 (23901124) 3
22 (25313245) 2
24 (23297332) 1
41 (28648873) 4
32 (28516226) Good
23 (29869961) 1
29 (29571797) 2
27 (28083822) 1
5 (26501536) 4
26 (25599513) 2
38 (25413699) Inadequate
34 (25415718) 4
21 (30107542) Good
35 (21257850) 4
20 (31078459) 1
25 (30777808) 3
36 (33141657) 3
28 (32721031) 3
43 (33223001) 4
37 (33650900) 3
11 (34154984) 4
30 (16775176) Good
33 (33706172) Good
6 (-3196037) 4
3 (37150275) 4
31 (20868890) 4
10 (38687505) 4
9 (38687503) 4
Mammography screening Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
1 (21712474) 1
7 (26757170) 4
44 (26204111) 4
41 (28648873) 4
2 (24450666) 3
29 (29571797) 2
39 (29267146) 4
42 (28411671) 4
40 (27754936) 4
5 (26501536) 4
38 (25413699) Inadequate
34 (25415718) 4
35 (21257850) 4
36 (33141657) 3
43 (33223001) 4
37 (33650900) 3
11 (34154984) 4
30 (16775176) Good
6 (-3196037) 4
3 (37150275) 4
31 (20868890) 4
10 (38687505) 4
9 (38687503) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
52 (22723501) 2
67 (22474203) 1
72 (28655029) 3
82 (30098212) 3
57 (29736009) Good
29 (29571797) 2
54 (27501888) 1
13 (34794600) 4
56 (33434108) 3
43 (33223001) 4
58 (34406400) 2
55 (34134531) 4
53 (30316869) 1
30 (16775176) Good
Mammography with IV contrast May be appropriate Strong ☢☢ 0.1-1mSv 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
64 (30240292) 2
65 (31453765) 2
62 (33787291) 3
63 (31092346) 2
66 (39509749) 2
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
67 (22474203) 1
68 (20177029) 1
70 (19884532) 1
72 (28655029) 3
76 (24934793) 3
75 (27097237) 4
71 (31063080) 3
74 (31221620) 3
69 (25794083) 4
73 (32303988) Inadequate
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 0 0 0 0 0
References Study Quality
81 (28506511) 4
80 (25454099) 2
77 (24958821) 2
48 (32096852) 1
56 (33434108) 3
78 (33620293) 3
79 (31206889) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 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 0 0 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 0 0 0 0 0 0 0 0 0
References Study Quality
50 (31880677) 4
51 (32524221) 2
43 (33223001) 4
Variant 3: Adult female 30 years of age or older. 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 1 0 0 3 1 1 15
References Study Quality
95 (34324686) 4
94 (37673117) 4
93 (36927127) 4
92 (27444927) 4
91 (21079137) 4
90 (31233143) 3
89 (19176458) Good
88 (26908327) Inadequate
43 (33223001) 4
38 (25413699) Inadequate
37 (33650900) 3
36 (33141657) 3
35 (21257850) 4
34 (25415718) 4
33 (33706172) Good
32 (28516226) Good
30 (16775176) Good
29 (29571797) 2
28 (32721031) 3
27 (28083822) 1
26 (25599513) 2
25 (30777808) 3
24 (23297332) 1
23 (29869961) 1
22 (25313245) 2
21 (30107542) Good
20 (31078459) 1
19 (23901124) 3
18 (24918774) 3
17 (25058084) 3
11 (34154984) 4
10 (38687505) 4
9 (38687503) 4
6 (-3196037) 4
5 (26501536) 4
3 (37150275) 4
Mammography screening Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 1 0 0 1 0 3 16
References Study Quality
96 (28886475) Inadequate
95 (34324686) 4
94 (37673117) 4
93 (36927127) 4
92 (27444927) 4
91 (21079137) 4
90 (31233143) 3
89 (19176458) Good
88 (26908327) Inadequate
44 (26204111) 4
43 (33223001) 4
42 (28411671) 4
41 (28648873) 4
40 (27754936) 4
39 (29267146) 4
38 (25413699) Inadequate
37 (33650900) 3
36 (33141657) 3
35 (21257850) 4
34 (25415718) 4
30 (16775176) Good
29 (29571797) 2
11 (34154984) 4
10 (38687505) 4
9 (38687503) 4
7 (26757170) 4
6 (-3196037) 4
5 (26501536) 4
3 (37150275) 4
2 (24450666) 3
1 (21712474) 1
MRI breast without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 0 2 3 14
References Study Quality
96 (28886475) Inadequate
95 (34324686) 4
93 (36927127) 4
76 (24934793) 3
75 (27097237) 4
74 (31221620) 3
73 (32303988) Inadequate
72 (28655029) 3
71 (31063080) 3
70 (19884532) 1
69 (25794083) 4
68 (20177029) 1
67 (22474203) 1
43 (33223001) 4
4 (17392385) 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 1 1 1 10 2 6
References Study Quality
81 (28506511) 4
80 (25454099) 2
79 (31206889) 3
78 (33620293) 3
4 (17392385) 4
3 (37150275) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 1 1 1 3 10 4 0 0 1
References Study Quality
98 (16293877) 2
82 (30098212) 3
72 (28655029) 3
70 (19884532) 1
69 (25794083) 4
68 (20177029) 1
67 (22474203) 1
13 (34794600) 4
Mammography with IV contrast May be appropriate Strong ☢☢ 0.1-1mSv 5 5 0 0 2 0 13 3 1 1 1
References Study Quality
97 (39058970) 1
66 (39509749) 2
65 (31453765) 2
64 (30240292) 2
63 (31092346) 2
62 (33787291) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 2 2 0 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 18 1 2 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 5 5 3 1 5 1 1 0 0
References Study Quality
43 (33223001) 4
50 (31880677) 4
51 (32524221) 2
Variant 4: Adult female younger than 30 years of age. 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
MRI breast without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 1 1 3 7 8
References Study Quality
96 (28886475) Inadequate
95 (34324686) 4
93 (36927127) 4
76 (24934793) 3
75 (27097237) 4
74 (31221620) 3
73 (32303988) Inadequate
72 (28655029) 3
71 (31063080) 3
70 (19884532) 1
69 (25794083) 4
68 (20177029) 1
67 (22474203) 1
43 (33223001) 4
4 (17392385) 4
3 (37150275) 4
MRI breast without and with IV contrast abbreviated Usually appropriate Expert Opinion O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 2 0 12 4 2
References Study Quality
3 (37150275) 4
4 (17392385) 4
81 (28506511) 4
80 (25454099) 2
79 (31206889) 3
78 (33620293) 3
US breast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 17 1 1 0 0
References Study Quality
98 (16293877) 2
82 (30098212) 3
72 (28655029) 3
70 (19884532) 1
69 (25794083) 4
68 (20177029) 1
67 (22474203) 1
13 (34794600) 4
Digital breast tomosynthesis screening May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 0 0 0 2 16 2 1 0 0
References Study Quality
95 (34324686) 4
94 (37673117) 4
93 (36927127) 4
92 (27444927) 4
91 (21079137) 4
90 (31233143) 3
89 (19176458) Good
88 (26908327) Inadequate
43 (33223001) 4
33 (33706172) Good
32 (28516226) Good
30 (16775176) Good
29 (29571797) 2
28 (32721031) 3
27 (28083822) 1
26 (25599513) 2
25 (30777808) 3
24 (23297332) 1
23 (29869961) 1
22 (25313245) 2
21 (30107542) Good
20 (31078459) 1
19 (23901124) 3
18 (24918774) 3
17 (25058084) 3
3 (37150275) 4
Mammography screening May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 0 0 1 2 14 3 0 0 1
References Study Quality
96 (28886475) Inadequate
95 (34324686) 4
94 (37673117) 4
93 (36927127) 4
92 (27444927) 4
91 (21079137) 4
90 (31233143) 3
89 (19176458) Good
88 (26908327) Inadequate
44 (26204111) 4
43 (33223001) 4
41 (28648873) 4
40 (27754936) 4
39 (29267146) 4
38 (25413699) Inadequate
35 (21257850) 4
30 (16775176) Good
29 (29571797) 2
11 (34154984) 4
10 (38687505) 4
7 (26757170) 4
5 (26501536) 4
3 (37150275) 4
2 (24450666) 3
1 (21712474) 1
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 10 3 4 0 3 1 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 2 0 0 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 20 1 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 2 1 1 1 0 0 0 0
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.