Examination of fully automated mammographic density measures using LIBRA and breast cancer risk in a cohort of 21,000 non-Hispanic white women

Laurel A. Habel, Stacey E. Alexeeff, Ninah Achacoso, Vignesh A. Arasu, Aimilia Gastounioti, Lawrence Gerstley, Robert J. Klein, Rhea Y. Liang, Jafi A. Lipson, Walter Mankowski, Laurie R. Margolies, Joseph H. Rothstein, Daniel L. Rubin, Li Shen, Adriana Sistig, Xiaoyu Song, Marvella A. Villaseñor, Mark Westley, Alice S. Whittemore, Martin J. YaffePei Wang, Despina Kontos, Weiva Sieh

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Breast density is strongly associated with breast cancer risk. Fully automated quantitative density assessment methods have recently been developed that could facilitate large-scale studies, although data on associations with long-term breast cancer risk are limited. We examined LIBRA assessments and breast cancer risk and compared results to prior assessments using Cumulus, an established computer-assisted method requiring manual thresholding. Methods: We conducted a cohort study among 21,150 non-Hispanic white female participants of the Research Program in Genes, Environment and Health of Kaiser Permanente Northern California who were 40–74 years at enrollment, followed for up to 10 years, and had archived processed screening mammograms acquired on Hologic or General Electric full-field digital mammography (FFDM) machines and prior Cumulus density assessments available for analysis. Dense area (DA), non-dense area (NDA), and percent density (PD) were assessed using LIBRA software. Cox regression was used to estimate hazard ratios (HRs) for breast cancer associated with DA, NDA and PD modeled continuously in standard deviation (SD) increments, adjusting for age, mammogram year, body mass index, parity, first-degree family history of breast cancer, and menopausal hormone use. We also examined differences by machine type and breast view. Results: The adjusted HRs for breast cancer associated with each SD increment of DA, NDA and PD were 1.36 (95% confidence interval, 1.18–1.57), 0.85 (0.77–0.93) and 1.44 (1.26–1.66) for LIBRA and 1.44 (1.33–1.55), 0.81 (0.74–0.89) and 1.54 (1.34–1.77) for Cumulus, respectively. LIBRA results were generally similar by machine type and breast view, although associations were strongest for Hologic machines and mediolateral oblique views. Results were also similar during the first 2 years, 2–5 years and 5–10 years after the baseline mammogram. Conclusion: Associations with breast cancer risk were generally similar for LIBRA and Cumulus density measures and were sustained for up to 10 years. These findings support the suitability of fully automated LIBRA assessments on processed FFDM images for large-scale research on breast density and cancer risk.

Original languageEnglish
Article number92
JournalBreast Cancer Research
Issue number1
StatePublished - Dec 2023


  • Breast cancer
  • Epidemiology
  • Mammographic density
  • Mammography
  • Risk factors


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