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Early detection with screening mammography significantly reduces breast cancer deaths by 20% to 40%.
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Annual screening mammography of women aged 40 to 84 prevents more deaths from breast cancer than biennial screening of women 50 to 74 years old.
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Currently, it is recommended that supplemental screening with ultrasound or MR imaging be performed in addition to mammography.
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The American Cancer Society recommends annual screening mammography and supplemental screening MR imaging for women with an
Screening for Breast Cancer
Section snippets
Key points
Screening mammography
Early detection of breast cancer with screening mammography significantly reduces the risk of death from the disease.3, 4 The strongest evidence is provided by randomized controlled trials (RCTs), and pooled estimates show that screening mammography can reduce breast cancer mortality by at least 20%.5 Eight RCTs have been performed and published. The first was initiated in 1963, the Health Insurance Plan (HIP) trial.6 It recruited 62,000 women ages 40 to 64 from the HIP of greater New York and
Performance benchmarks for screening mammography
Screening mammography detects 2 to 8 cancers per 1000 mammograms.25, 26, 27 The sensitivity of mammography decreases in women with dense breasts, measuring 30% to 64% for extremely dense breasts compared with 76% to 98% for fatty breasts.28, 29, 30, 31, 32, 33 Decreased sensitivity in denser breasts is attributable to the concept of masking. Cancers have similar x-ray attenuation as dense fibroglandular tissue, resulting in obscuration of the tumor.31 With this limitation, supplemental
Digital breast tomosynthesis
Digital breast tomosynthesis (DBT) is a digital mammogram technique in which tomosynthesis images are constructed from a series of low-dose images acquired as the x-ray source moves over the breast, which reduces the impact of overlapping breast tissue. Eliminating tissue overlap increases conspicuity of lesions while reducing false positives due to tissue summation. DBT detects malignancies occult on digital mammography (Fig. 2).34 Two major prospective clinical trials have been performed
Contrast-enhanced mammography and digital breast tomosynthesis
Neovascularity causes tumors to enhance, usually more so than the surrounding normal parenchyma, following administration of intravenous contrast agents. Contrast-enhanced spectral mammography (CESM) or DBT acquires FFDM or DBT images following intravenous iodine-based contrast media injection. A recent meta-analysis of CESM demonstrated very high sensitivity (98%) but limited specificity (58%).39 At this time, CESM and CE-DBT remain active areas of research and are not currently recommended
Screening ultrasound
Ultrasound has shown utility in detecting breast cancer as a supplemental screening modality since the 1980s.40, 41 Compared with screening mammography alone, screening ultrasound in combination with mammography can increase cancer detection (additional cancer detection rate [ACDR]) but at the cost of increased callbacks (“recall rate”) and a large number of biopsies needed to identify 1 breast cancer (positive predictive value 3 [PPV3] = number of cancers detected/number of biopsies performed).
Screening breast MR imaging
Breast MR imaging with gadolinium is highly sensitive (≥90%) for the detection of breast cancer.52, 53, 54 Although initial reports suggested lower sensitivity for the detection of ductal carcinoma in situ (DCIS), advances in image quality and image interpretation have resulted in 98% and 85% sensitivities for high-grade and non–high-grade DCIS, respectively.55 In prospective trials of asymptomatic high-risk women, screening MR imaging was more sensitive (90%–93%) than clinical breast
Additional breast imaging modalities
Positron emission mammography (PEM) remains investigational but uses mild compression with acquisitions in 2 views, similar to mammography. Data from experienced readers suggest sensitivity of 90% to 96%, although PEM may not reliably detect lower-grade malignancies and has a higher radiation dose than mammography, limiting its screening utility.62, 63, 64, 65, 66, 67 Breast-specific gamma imaging (BSGI) uses a radiotracer, most commonly 99mTc-sestamibi, which accumulates in tumor more than
Breast cancer screening guidelines
The US Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), and the American College of Radiology (ACR) are the 3 main organizations that have issued evidence-based guidelines for breast cancer screening in the average-risk woman based on estimates of risk versus benefits (Table 2).5, 76, 77 All 3 organizations agree that screening mammography saves lives, and, at a minimum, should be performed in women 50 to 74. All 3 guidelines recognize that annual mammography should
Women with dense breasts
Approximately 40% to 50% of women undergoing screening mammography have dense breasts (higher ratio of fibroglandular and stromal elements relative to fatty tissue).85 The definition of “dense” is subjective by the radiologist and demonstrates moderate variability between radiologists with 17% of patients being recategorized into dense versus nondense on subsequent mammograms.86 Women with dense breasts have a 1.2-fold to 2.1-fold higher risk of breast cancer compared with the average woman.87
“Risk-based” or “personalized” or “tailored” screening
In the emerging era of precision medicine, it is unlikely that there will be a “one-size-fits-all” approach to breast cancer screening. Women at increased risk of breast cancer may benefit from supplemental screening with imaging examinations, such as DBT, MR imaging, or ultrasound. Supplemental screening should be in addition to, and not as a replacement for, annual mammography.
The 20% to 40% reduction in breast cancer mortality was observed in screening mammography RCTs and service screening
Screening average-risk or low-risk women
Women who have less than 15% lifetime risk of breast cancer should continue to be offered screening mammography annually starting at the age of 40 per ACR guidelines. The ACS and the USPSTF, who advise routinely starting screening at a later date (45–50), acknowledge that the most lives are saved from breast cancer when screening starts at 40 and is performed annually.5, 77 Women of average or low risk require no additional supplemental screening in addition to mammography, although the NCCN
Screening intermediate-risk women
Women with an intermediate risk of breast cancer (15% to <20% lifetime risk) include women with a prior personal history of breast cancer, lobular neoplasia, and other atypias. Some consider women with dense breasts in the intermediate-risk category. For women with 15% to less than 20% lifetime risk, the 2007 ACS guidelines state that there was insufficient evidence to recommend for or against supplemental breast MR imaging.95 Subsequently published studies in women with a personal history of
Screening high-risk women
Since 2007, the ACS has recommended annual screening mammography and supplemental screening MR imaging for women with an estimated lifetime risk of breast cancer ≥20%, BRCA mutation carriers, first-degree relatives of BRCA mutation carriers who remain untested, women with a history of mediastinal irradiation between the ages of 10 and 30, and women with certain genetic syndromes (Li-Fraumeni, Cowden, Bannayan-Riley-Ruvalcaba).95 Many statistical models have been developed to assess breast
Benefits and “Harms” of Screening
Individuals and different professional organizations disagree about the relative benefits and harms of screening mammography, resulting in hotly debated controversies. Breast cancer–specific mortality reduction is the primary benefit of screening mammography, but not the only one. Earlier detection and treatment of breast cancers results not only in decreased breast cancer deaths but also decreased treatment-related morbidity; that is, fewer mastectomies and less frequent and less toxic
Summary
The ACS, ACR, and the USPSTF, as well as every medical professional organization, to our knowledge, agree that screening mammography significantly decreases breast cancer mortality. Although screening mammography is covered as a preventive care benefit without cost sharing under the Patient Protection and Affordable Care Act, nearly one-third of US women older than 40 are not receiving regular screening mammograms. In 2013, fewer than 66% of women older than 40 in the United States had a
References (131)
- et al.
The randomized trials of breast cancer screening: what have we learned?
Radiol Clin North Am
(2004) - et al.
Reduction in mortality from breast cancer after mass screening with mammography. Randomised trial from the Breast Cancer Screening Working Group of the Swedish National Board of Health and Welfare
Lancet
(1985) - et al.
Long-term effects of mammography screening: updated overview of the Swedish randomised trials
Lancet
(2002) - et al.
14 years of follow-up from the Edinburgh randomised trial of breast-cancer screening
Lancet
(1999) - et al.
Breast density and breast cancer risk: a practical review
Mayo Clin Proc
(2014) - et al.
Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study
Lancet Oncol
(2013) - et al.
Diagnostic performance of contrast-enhanced spectral mammography: systematic review and meta-analysis
Breast
(2016) - et al.
Sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the Japan Strategic Anti-cancer Randomized Trial (J-START): a randomised controlled trial
Lancet
(2016) - et al.
MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study
Lancet
(2007) - et al.
F-18 fluorodeoxyglucose-positron emission tomography imaging for primary breast cancer and loco-regional staging
Radiol Clin North Am
(2007)
ACR appropriateness criteria breast cancer screening
J Am Coll Radiol
Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer
J Am Coll Radiol
The use of breast imaging to screen women at high risk for cancer
Radiol Clin North Am
Screening breast MRI in patients previously treated for breast cancer: diagnostic yield for cancer and abnormal interpretation rate
Acad Radiol
Cancer facts and figures 2017
Insights from the breast cancer screening trials: how screening affects the natural history of breast cancer and implications for evaluating service screening programs
Breast J
Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society
JAMA
Periodic breast cancer screening in reducing mortality from breast cancer
JAMA
Periodic screening for breast cancer: the Health Insurance Plan project and its sequelae, 1963–1986
Periodic screening for breast cancer: the HIP randomized controlled trial. Health insurance plan
J Natl Cancer Inst Monogr
Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades
Radiology
Edinburgh trial of screening for breast cancer: mortality at seven years
Lancet
Followup after 11 years–update of mortality results in the Stockholm mammographic screening trial
Breast Cancer Res Treat
Canadian National Breast Screening Study: 2. Breast cancer detection and death rates among women aged 50 to 59 years
CMAJ
Canadian National Breast Screening Study: 1. Breast cancer detection and death rates among women aged 40 to 49 years
CMAJ
Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial
BMJ
The Canadian National Breast Screening Study: a critical review
AJR Am J Roentgenol
The role of the reference radiologist. Estimates of inter-observer agreement and potential delay in cancer detection in the national breast screening study
Invest Radiol
The Gothenburg Breast Cancer Screening Trial: preliminary results on breast cancer mortality for women aged 39-49
J Natl Cancer Inst Monogr
The Gothenburg Breast Screening Trial
Cancer
The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies
J Med Screen
Pan-Canadian study of mammography screening and mortality from breast cancer
J Natl Cancer Inst
Mammographic screening and breast cancer mortality: a case-control study and meta-analysis
Cancer Epidemiol Biomarkers Prev
The national mammography database: preliminary data
AJR Am J Roentgenol
Criteria for identifying radiologists with acceptable screening mammography interpretive performance on basis of multiple performance measures
AJR Am J Roentgenol
ACR BI-RADS® Atlas, breast imaging reporting and data system
Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography
Ann Intern Med
Breast cancer screening effect across breast density strata: a case-control study
Int J Cancer
Breast density as a predictor of mammographic detection: comparison of interval- and screen-detected cancers
J Natl Cancer Inst
Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations
Radiology
Screening breast ultrasound: past, present, and future
AJR Am J Roentgenol
Digital tomosynthesis in breast imaging
Radiology
Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program
Radiology
Breast cancer screening with tomosynthesis and digital mammography-reply
JAMA
Comparison of two-dimensional synthesized mammograms versus original digital mammograms alone and in combination with tomosynthesis images
Radiology
Thermography and ultrasound in detection and diagnosis of breast cancer
Cancer
Breast cancer detection with sonography and mammography: comparison using state-of-the-art equipment
AJR Am J Roentgenol
Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer
JAMA
Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk
JAMA
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Disclosure Statement: The authors have nothing to disclose.