Breast density implications and supplemental screening.

Digital breast tomosynthesis (DBT) has been widely implemented in place of 2D mammography, although it is less effective in women with extremely dense breasts. Breast ultrasound detects additional early-stage, invasive breast cancers when combined with mammography; however, its relevant limitations, including the shortage of trained operators, operator dependence and small field of view, have limited its widespread implementation. Automated breast sonography (ABS) is a promising technique but the time to interpret and false-positive rates need to be improved. Supplemental screening with contrast-enhanced magnetic resonance imaging (MRI) in high-risk women reduces late-stage disease; abbreviated MRI protocols may reduce cost and increase accessibility to women of average risk with dense breasts. Contrast-enhanced digital mammography (CEDM) and molecular breast imaging improve cancer detection but require further validation for screening and direct biopsy guidance should be implemented for any screening modality. This article reviews the status of screening women with dense breasts. KEY POINTS: • The sensitivity of mammography is reduced in women with dense breasts. Supplemental screening with US detects early-stage, invasive breast cancers. • Tomosynthesis reduces recall rate and increases cancer detection rate but is less effective in women with extremely dense breasts. • Screening MRI improves early diagnosis of breast cancer more than ultrasound and is currently recommended for women at high risk. Risk assessment is needed, to include breast density, to ascertain who should start early annual MRI screening.

The performance of 3D ABUS versus HHUS in the visualisation and BI-RADS characterisation of breast lesions in a large cohort of 1,886 women.

OBJECTIVES: This study aimed to evaluate automated breast ultrasound (ABUS) compared to hand-held traditional ultrasound (HHUS) in the visualisation and BIRADS characterisation of breast lesions. MATERIALS AND METHODS: From January 2016 to January 2017, 1,886 women with breast density category C or D (aged 48.6±10.8 years) were recruited. All participants underwent ABUS and HHUS examination; a subcohort of 1,665 women also underwent a mammography. RESULTS: The overall agreement between HHUS and ABUS was 99.8 %; kappa=0.994, p<0.0001. Two cases were graded as BI-RADS 1 in HHUS, but were graded as BIRADS 4 in ABUS; biopsy revealed a radial scar. Three carcinomas were graded as BI-RADS 2 in mammography but BI-RADS 4 in ABUS; two additional carcinomas were graded as BI-RADS 2 in mammography but BI-RADS 5 in ABUS. Two carcinomas, appearing as a well-circumscribed mass or developing asymmetry in mammography, were graded as BI-RADS 4 in mammography but BI-RADS 5 in ABUS. CONCLUSIONS: ABUS could be successfully used in the visualisation and characterisation of breast lesions. ABUS seemed to outperform HHUS in the detection of architectural distortion on the coronal plane and can supplement mammography in the detection of non-calcified carcinomas in women with dense breasts. KEY POINTS: • The new generation of ABUS yields comparable results to HHUS. • ABUS seems superior to HHUS in detecting architectural distortions. • In dense breasts, supplemental ABUS to mammography detects additional cancers.

Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey.

EUSOBI and 30 national breast radiology bodies support mammography for population-based screening, demonstrated to reduce breast cancer (BC) mortality and treatment impact. According to the International Agency for Research on Cancer, the reduction in mortality is 40 % for women aged 50-69 years taking up the invitation while the probability of false-positive needle biopsy is <1 % per round and overdiagnosis is only 1-10 % for a 20-year screening. Mortality reduction was also observed for the age groups 40-49 years and 70-74 years, although with "limited evidence". Thus, we firstly recommend biennial screening mammography for average-risk women aged 50-69 years; extension up to 73 or 75 years, biennially, is a second priority, from 40-45 to 49 years, annually, a third priority. Screening with thermography or other optical tools as alternatives to mammography is discouraged. Preference should be given to population screening programmes on a territorial basis, with double reading. Adoption of digital mammography (not film-screen or phosphor-plate computer radiography) is a priority, which also improves sensitivity in dense breasts. Radiologists qualified as screening readers should be involved in programmes. Digital breast tomosynthesis is also set to become "routine mammography" in the screening setting in the next future. Dedicated pathways for high-risk women offering breast MRI according to national or international guidelines and recommendations are encouraged. KEY POINTS: • EUSOBI and 30 national breast radiology bodies support screening mammography. • A first priority is double-reading biennial mammography for women aged 50-69 years. • Extension to 73-75 and from 40-45 to 49 years is also encouraged. • Digital mammography (not film-screen or computer radiography) should be used. • DBT is set to become "routine mammography" in the screening setting in the next future.

Screening Breast Ultrasound Using Handheld or Automated Technique in Women with Dense Breasts.

In women with dense breasts (heterogeneously or extremely dense), adding screening ultrasound to mammography increases detection of node-negative invasive breast cancer. Similar incremental cancer detection rates averaging 2.1-2.7 per 1000 have been observed for physician- and technologist-performed handheld ultrasound (HHUS) and automated ultrasound (AUS). Adding screening ultrasound (US) for women with dense breasts significantly reduces interval cancer rates. Training is critical before interpreting examinations for both modalities, and a learning curve to achieve optimal performance has been observed. On average, about 3% of women will be recommended for biopsy on the prevalence round because of screening US, with a wide range of 2%-30% malignancy rates for suspicious findings seen only on US. Breast Imaging Reporting and Data System 3 lesions identified only on screening HHUS can be safely followed at 1 year rather than 6 months. Computer-aided detection and diagnosis software can augment performance of AUS and HHUS; ongoing research on machine learning and deep learning algorithms will likely improve outcomes and workflow with screening US.