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Br J Cancer. 2014 Apr 2;110(7):1908-16. doi: 10.1038/bjc.2014.82. Epub 2014 Feb 20.

Comparison of fully and semi-automated area-based methods for measuring mammographic density and predicting breast cancer risk.

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Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
1] Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117597, Singapore [2] Human Genetics Lab, Genome Institute of Singapore, 60 Biopolis Street, 02-01, Singapore 138672, Singapore.
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Box 281, Stockholm 17177, Sweden.
Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, Charterhouse Square, London EC1M 6BQ, UK.
Environment and Radiation Section, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon, France.



Mammographic density is a strong risk factor for breast cancer but the lack of valid fully automated methods for quantifying it has precluded its use in clinical and screening settings. We compared the performance of a recently developed automated approach, based on the public domain ImageJ programme, to the well-established semi-automated Cumulus method.


We undertook a case-control study within the intervention arm of the Age Trial, in which ∼54,000 British women were offered annual mammography at ages 40-49 years. A total of 299 breast cancer cases diagnosed during follow-up and 422 matched (on screening centre, date of birth and dates of screenings) controls were included. Medio-lateral oblique (MLO) images taken closest to age 41 and at least one year before the index case's diagnosis were digitised for each participant. Cumulus readings were performed in the left MLO and ImageJ-based readings in both left and right MLOs. Conditional logistic regression was used to examine density-breast cancer associations.


The association between density readings taken from one single MLO and breast cancer risk was weaker for the ImageJ-based method than for Cumulus (age-body mass index-adjusted odds ratio (OR) per one s.d. increase in percent density (95% CI): 1.52 (1.24-1.86) and 1.61 (1.33-1.94), respectively). The ImageJ-based density-cancer association strengthened when the mean of left-right MLO readings was used: OR=1.61 (1.31-1.98).


The mean of left-right MLO readings yielded by the ImageJ-based method was as strong a predictor of risk as Cumulus readings from a single MLO image. The ImageJ-based method, using the mean of two measurements, is a valid automated alternative to Cumulus for measuring density in analogue films.

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