Triple test score

To obtain the triple test score, a number from 1 through 3 is assigned to each one of the procedures. A score of 1 is assigned to a benign test result, 2 applies to a suspicious test result, and 3 applies to a malignant result. The sum of the scores of all three procedures is the triple test score.

If the total summed score from the three tests is 3 to 4 then the diagnosis is most likely benign. A total summed score of 5 is considered suspicious. A score of 6 or greater is possibly malignant. There have been different inclusions for the components of the triple test score in the past, such as using the procedures of physical examination, mammography, and cytology. Other versions of the triple test score have included mammography, ultrasound, and magnetic resonance imaging (MRI).{{cite journal |vauthors=Egyed Z, Járay B, Kulka J, Péntek Z |date=28 August 2008 |title=Triple test score for the evaluation of invasive ductal and lobular breast cancer |journal=Pathology & Oncology Research |volume=15 |issue=2 |pages=159–166 |doi=10.1007/s12253-008-9083-3 |pmid=18752055 |s2cid=6523239}}

The TTS was first implemented and then changed to create a modified TTS. The main difference between the two diagnostic tools is the substitution of the mammogram for the ultrasound in persons under the age of 40.{{cite journal | vauthors = Harvey JA | title = Sonography of Palpable Breast Masses | journal = Seminars in Ultrasound, CT, and MR | volume = 27 | issue = 4 | pages = 284–297 | date = August 2006 | pmid = 16915997 | doi = 10.1053/j.sult.2006.05.003 | series = Breast Imaging Update }}{{cite journal | vauthors = Morris KT, Vetto JT, Petty JK, Lum SS, Schmidt WA, Toth-Fejel S, Pommier RF | title = A new score for the evaluation of palpable breast masses in women under age 40 | journal = American Journal of Surgery | volume = 184 | issue = 4 | pages = 346–347 | date = October 2002 | pmid = 12383898 | doi = 10.1016/S0002-9610(02)00947-9 }} This is because ultrasound has been found to be more effecting at early detection of breast cancer and masses for persons with denser breast tissues. These individuals with denser breast tissues have also been found to be at an increased risk of developing breast cancer.{{cite journal | vauthors = Thigpen D, Kappler A, Brem R | title = The Role of Ultrasound in Screening Dense Breasts-A Review of the Literature and Practical Solutions for Implementation | journal = Diagnostics | volume = 8 | issue = 1 | pages = 20 | date = March 2018 | pmid = 29547532 | pmc = 5872003 | doi = 10.3390/diagnostics8010020 | doi-access = free }} Most modified TTS exams contain a combination of physical examination, ultrasound, and needle biopsy.{{cite journal | vauthors = Kachewar SS, Dongre SD | title = Role of triple test score in the evaluation of palpable breast lump | journal = Indian Journal of Medical and Paediatric Oncology | volume = 36 | issue = 2 | pages = 123–127 | date = 2015 | pmid = 26157290 | pmc = 4477375 | doi = 10.4103/0971-5851.158846 | doi-access = free }} There are no changes to the scoring system of the mTSS.

Like the triple test score, BI-RADS (breast imaging-reporting and data system) uses a similar method of scoring breast imaging reports to help with evaluating and determining treatment for breast masses.{{cite book | vauthors = Magny SJ, Shikhman R, Keppke AL | chapter = Breast Imaging Reporting and Data System |date=August 29, 2022 | chapter-url = http://www.ncbi.nlm.nih.gov/books/NBK459169/ |title =StatPearls |access-date=2023-07-30 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29083600 }} Like the triple test score, BI-RADS employs a numerical scoring system to determine whether a mass is benign or malignant. The triple test score assigns a numerical indicator of 1 to 3 while BI-RADS assigns a numerical indicator of 1 to 6. The BI-RADS scoring for mammograms can be comparable to the triple test score's scoring for mammograms. For instance, a BI-RADS of 1 or 2 is equivalent to a triple test score of 1. Similar to the triple test score, a lower scoring on BI-RADS (i.e. 1 or 2) is indicative of a benign screening while a high scoring (i.e. 5 or 6) is indicative of malignancy.

Unlike the triple test score which scores three different exams, BI-RADS focuses on evaluating findings from one exam: mammograms.

The triple test score reduces cost for evaluating breast masses compared to traditional methods due to reducing the likelihood of people undergoing an excisional biopsy while still providing effective diagnoses. An excisional biopsy can be performed to remove a palpable breast mass. Because of the triple test score's high accuracy, it can be used to replace excisional biopsy if all three portions of the triple test score are scored a 1 (benign), indicating that the mass does not necessarily need to be removed.{{cite journal | vauthors = Morris KT, Pommier RF, Morris A, Schmidt WA, Beagle G, Alexander PW, Toth-Fejel S, Schmidt J, Vetto JT | display-authors = 6 | title = Usefulness of the triple test score for palpable breast masses; discussion 1012-3 | journal = Archives of Surgery | volume = 136 | issue = 9 | pages = 1008–1012 | date = September 2001 | pmid = 11529822 | doi = 10.1001/archsurg.136.9.1008 | s2cid = 22625052 | doi-access = }} Cost differences between the traditional methods and the triple test score varied based on the stages of breast mass evaluation. Traditional methods of evaluating breast masses include radiological assessments (e.g. mammography, ultrasound, MRI) and pathologic analyses (e.g. fine-needle aspiration cytology, core biopsy).{{cite book | vauthors = Daly C, Puckett Y | chapter = New Breast Mass |date=August 1, 2022 | chapter-url= http://www.ncbi.nlm.nih.gov/books/NBK560757/ | title = StatPearls |access-date=2023-07-29 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=32809592 }} During early work-up stages to evaluate suspicion of a breast mass—such as mammography imaging due to a palpable mass—triple test score was found to cost more than traditional methods. During diagnosis of malignancy, triple test score was found to cost less than traditional methods.{{cite journal | vauthors = Morris AM, Flowers CR, Morris KT, Schmidt WA, Pommier RF, Vetto JT | title = Comparing the cost-effectiveness of the triple test score to traditional methods for evaluating palpable breast masses | journal = Medical Care | volume = 41 | issue = 8 | pages = 962–971 | date = August 2003 | pmid = 12886175 | doi = 10.1097/00005650-200308000-00009 | s2cid = 41315487 }}

A physical exam of the breast is one of the three tests that is scored that is a part of a triple test score.{{cite journal | vauthors = Klein S | title = Evaluation of palpable breast masses | language = en-US | journal = American Family Physician | volume = 71 | issue = 9 | pages = 1731–1738 | date = May 2005 | pmid = 15887452 | url = https://www.aafp.org/pubs/afp/issues/2005/0501/p1731.html }} A clinical breast examination (CBE) is different from a breast self-exam because a CBE is conducted by a physician during an appointment whereas a self-exam is recommend to be conducted monthly by patients at home. The physician will ask the patient to stand in various poses during a CBE because this will allow them to look for abnormalities that may be present in a patient's breast.{{Cite web |title=Clinical Breast Exam |url=https://www.nationalbreastcancer.org/clinical-breast-exam |access-date=2023-07-30 |website=National Breast Cancer Foundation |language=en-US}} An overview of 11 different systemic reviews summarized the effectiveness of a clinical breast examination as the sole method of screening for breast cancer by using sensitivity, specificity and positive predictive value as measures of accuracy. A total of 8 out of 11 reviews reported a sensitivity range between 40% and 69% which when averaged gave a result of 54.1%.{{cite journal | vauthors = Ngan TT, Nguyen NT, Van Minh H, Donnelly M, O'Neill C | title = Effectiveness of clinical breast examination as a 'stand-alone' screening modality: an overview of systematic reviews | journal = BMC Cancer | volume = 20 | issue = 1 | pages = 1070 | date = November 2020 | pmid = 33167942 | pmc = 7653771 | doi = 10.1186/s12885-020-07521-w | doi-access = free }}

File:Blausen 0628 Mammogram.png

Various imaging tests can be conducted, such as magnetic resonance imaging (MRI), ultrasound, or mammogram, as one of the three tests that is scored that is a part of a triple test score.{{Cite web |title=The Triple Test |url=https://www.breastcancerfoundation.org.nz/breast-cancer/tests-and-diagnosis/the-triple-test |access-date=2023-07-30 |website=www.breastcancerfoundation.org.nz}}

• An MRI can help detect malignancy with the use of contrast to help make the malignant lesions more pronounced. The sensitivity of an MRI ranges from 85–100% but the specificity ranges from 47–67%.
• An ultrasound can detect abnormalities in the breast tissue by using high-frequency sound waves that bounce off the tissue that then transform into images that can be interpreted. It has been shown to be more useful in searching for masses in dense breast tissue.{{cite journal | vauthors = Sood R, Rositch AF, Shakoor D, Ambinder E, Pool KL, Pollack E, Mollura DJ, Mullen LA, Harvey SC | display-authors = 6 | title = Ultrasound for Breast Cancer Detection Globally: A Systematic Review and Meta-Analysis | journal = Journal of Global Oncology | volume = 5 | issue = 5 | pages = 1–17 | date = August 2019 | pmid = 31454282 | pmc = 6733207 | doi = 10.1200/JGO.19.00127 }} Ultrasounds have a sensitivity of 76% and specificity of 84%.{{cite journal | vauthors = Chen HL, Zhou JQ, Chen Q, Deng YC | title = Comparison of the sensitivity of mammography, ultrasound, magnetic resonance imaging and combinations of these imaging modalities for the detection of small (≤2cm) breast cancer | journal = Medicine | volume = 100 | issue = 26 | pages = e26531 | date = July 2021 | pmid = 34190189 | pmc = 8257894 | doi = 10.1097/MD.0000000000026531 }}
• A mammogram is done via an X-ray machine that the patient stands against and places their breast firmly on top of a specific plate while another plate presses the breast from the top while the imaging is done.{{Cite web |date=2022-09-26 |title=What Is a Mammogram? |url=https://www.cdc.gov/cancer/breast/basic_info/mammograms.htm |access-date=2023-07-30 |website=Centers for Disease Control and Prevention |language=en-us}} Mammograms have a sensitivity range of 75–85% but that range does not apply to patients with dense or small breasts.

File:Needle Breast Biopsy.png

Over a review of 46 studies using sensitivity, specificity, and other measures of accuracy, fine-needle aspiration biopsy proved to be a very accurate yet minimally invasive diagnostic method for evaluating breast malignancy. With the exclusion of unsatisfactory samples, fine-needle aspiration biopsy sensitivity proportion was 0.927 and the specificity proportion was 0.948. In the unsatisfactory samples, the pooled sensitivity proportion was 0.920, and the pooled specificity proportion was 0.768.{{cite journal | vauthors = Yu YH, Wei W, Liu JL | title = Diagnostic value of fine-needle aspiration biopsy for breast mass: a systematic review and meta-analysis | journal = BMC Cancer | volume = 12 | pages = 41 | date = January 2012 | pmid = 22277164 | pmc = 3283452 | doi = 10.1186/1471-2407-12-41 | doi-access = free }}

One way that fine-needle aspiration biopsy cytology is reported is via the International Academy of Cytology (IAC) Yokohama System, which "defines five categories for reporting breast cytology, each with a clear descriptive term for the category, a definition, a risk of malignancy (ROM) and a suggested management algorithm."{{cite journal | vauthors = Field AS, Raymond WA, Rickard M, Arnold L, Brachtel EF, Chaiwun B, Chen L, Di Bonito L, Kurtycz DF, Lee AH, Lim E, Ljung BM, Michelow P, Osamura RY, Pinamonti M, Sauer T, Segara D, Tse G, Vielh P, Chong PY, Schmitt F | display-authors = 6 | title = The International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy Cytopathology | journal = Acta Cytologica | volume = 63 | issue = 4 | pages = 257–273 | date = 2019 | pmid = 31112942 | doi = 10.1159/000499509 | s2cid = 263539317 }} This suggested management algorithm may be particularly useful in countries utilizing the triple test score, as it can provide various management strategies based on the breast lesions from fine-needle aspiration biopsy.

In another review of 22 studies with over 10,000 subjects, using the IAC Yokohama Reporting System, fine-needle aspiration showed strong overall accuracy. "Sensitivity and specificity, with 95% confidence intervals, were 0.978 [0.968, 0.985] and 0.832 [0.76, 0.886] for the diagnostic cut-off of "Atypical considered positive for malignancy," 0.916 [0.892, 0.935] and 0.983 [0.97, 0.99] for the cut-off of "Suspicious of Malignancy considered positive," and 0.763 [0.706, 0.812] and 0.999 [0.994, 1] for the cut-off of "Malignant considered positive."{{cite journal | vauthors = Paul P, Azad S, Agrawal S, Rao S, Chowdhury N | title = Systematic Review and Meta-Analysis of the Diagnostic Accuracy of the International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy in Diagnosing Breast Cancer | journal = Acta Cytologica | volume = 67 | issue = 1 | pages = 1–16 | date = 2023 | pmid = 36412573 | doi = 10.1159/000527346 | s2cid = 253760182 | doi-access = free }}

The IAC Yokohama Reporting System was also evaluated on the pooled risk of malignancy in a meta analysis of 18 different studies with a total of 7,969 cases. They found that when considering both "suspicious" and "malignant" as positive results, the sensitivity was 91%, and the false positive rate was 2.33%.{{cite journal | vauthors = Nikas IP, Vey JA, Proctor T, AlRawashdeh MM, Ishak A, Ko HM, Ryu HS | title = The Use of the International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy | journal = American Journal of Clinical Pathology | volume = 159 | issue = 2 | pages = 138–145 | date = February 2023 | pmid = 36370120 | pmc = 9891409 | doi = 10.1093/ajcp/aqac132 }}

Overall, fine-needle aspiration cytopathology can greatly benefit low medical infrastructure communities as it is "minimally invasive and well-tolerated by patients, inexpensive, and requires minimal laboratory infrastructure and proceduralist costs." However, two major requirements that may slow the integration of fine-needle aspiration cytology is actually attaining or training pathologists and to encourage the use cytopathology in the education of local clinicians.{{cite journal | vauthors = Field AS | title = Cytopathology in Low Medical Infrastructure Countries: Why and How to Integrate to Capacitate Health Care | journal = Clinics in Laboratory Medicine | volume = 38 | issue = 1 | pages = 175–182 | date = March 2018 | pmid = 29412881 | doi = 10.1016/j.cll.2017.10.014 | series = Global Health and Pathology }}

Studies investigating the applicability and the effectiveness of the triple test score in the United States have ranged from the 1991 to 2010.{{cite journal | vauthors = Vetto J, Pommier R, Schmidt W, Wachtel M, DuBois P, Jones M, Thurmond A | title = Use of the "triple test" for palpable breast lesions yields high diagnostic accuracy and cost savings | journal = American Journal of Surgery | volume = 169 | issue = 5 | pages = 519–522 | date = May 1995 | pmid = 7747833 | doi = 10.1016/S0002-9610(99)80209-8 }} The current prevalence and usage of the triple test score in the United States are not well understood.

In the United Kingdom, the triple test score is usually referred to as the "triple assessment". The majority of hospitals in the UK have implemented rapid-access breast cancer screening clinics where the triple test score is used as a clinical diagnostic tool.{{Cite web |date=2018-07-18 |title=Overview {{!}} Early and locally advanced breast cancer: diagnosis and management {{!}} Guidance |url=https://www.nice.org.uk/guidance/ng101 |access-date=2023-07-26 |website=www.nice.org.uk}}{{Cite web | vauthors = Chalasani P, Stopeck AT, Thompson PA | date = May 2023 | veditors = Kiluk JV |title=Breast Cancer Workup: Approach Considerations, Breast Cancer Screening, Ultrasonography |url=https://emedicine.medscape.com/article/1947145-workup#c1 |access-date=2023-07-30 |website=emedicine.medscape.com |language=en}}

Ongoing research efforts are essential for the long-term effectiveness and applicability of the triple test score in healthcare settings.

Breast cancer is not a gender-specific disease; anyone who has breast tissue has a risk of getting breast cancer. Gendering guidelines for breast cancer excludes individuals who do not identify as female, which can potentially lead to late detection of breast cancer in those individuals. There has been a push by various healthcare providers to make guidelines more inclusive when it comes to breast cancer screenings and awareness.{{Cite web |date=October 18, 2021 |title=Breast Cancer Has No Gender |url=https://www.cedars-sinai.org/discoveries/breast-cancer-risk-across-genders.html |access-date=2023-08-02 |website=Cedars-Sinai |language=en-US}}{{Relevance?|date=December 2023}}

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