Breast Cancer Screening for Women at Higher-Than-Average Risk: Updated Recommendations From the ACR

Comparison of conventional diffusion-weighted imaging and multiplexed sensitivity-encoding combined with deep learning-based reconstruction in breast magnetic resonance imaging

PURPOSE

To evaluate the feasibility of multiplexed sensitivity-encoding (MUSE) with deep learning-based reconstruction (DLR) for breast imaging in comparison with conventional diffusion-weighted imaging (DWI) and MUSE alone.

METHODS

This study was conducted using conventional single-shot DWI and MUSE data of female participants who underwent breast magnetic resonance imaging (MRI) from June to December 2023. The k-space data in MUSE were reconstructed using both conventional reconstruction and DLR. Two experienced radiologists conducted quantitative analyses of DWI, MUSE, and MUSE-DLR images by obtaining the signal-to-noise ratio (SNR) and the contrast-to-noise ratio (CNR) of lesions and normal tissue and qualitative analyses by using a 5-point Likert scale to assess the image quality. Inter-reader agreement was assessed using the intraclass correlation coefficient (ICC). Image scores, SNR, CNR, and apparent diffusion coefficient (ADC) measurements among the three sequences were compared using the Friedman test, with significance defined at P < 0.05.

RESULTS

In evaluations of the images of 51 female participants using the three sequences, the two radiologists exhibited good agreement (ICC = 0.540-1.000, P < 0.05). MUSE-DLR showed significantly better SNR than MUSE (P < 0.001), while the ADC values within lesions and tissues did not differ significantly among the three sequences (P = 0.924, P = 0.636, respectively). In the subjective assessments, MUSE and MUSE-DLR scored significantly higher than conventional DWI in overall image quality, geometric distortion and axillary lymph node (P < 0.001).

CONCLUSION

In comparison with conventional DWI, MUSE-DLR yielded improved image quality with only a slightly longer acquisition time.

Extending breast cancer screening beyond age 45-64 years in China: A cost-effectiveness analysis

The optimal breast cancer (BC) screening age in China remains uncertain. In this study, we evaluated the benefits, harms, and cost-effectiveness of lowering the screening starting age from 45 to 35 years and extending the stopping age from 64 to 79 years in Chinese women at an average risk of progressing BC. Biennial screening showed a lower incremental cost-effectiveness ratio (ICER) compared to annual screening. Extending the screening age beyond 45-64 years in certain scenarios increased the number of false-positive results and each averted breast cancer deaths. Specifically, extending the starting age to 35 years reduced overdiagnosis rate to 10.8 % and had an incremental cost ratio of US$12,746 per quality-adjusted life year (QALY), falling below the cost-effectiveness threshold of US$18,346 per QALY. Regarding the ceasing age, the status quo (age 64 years) was found to be the optimal choice as it was proved to yield the majority of benefits with reduced harm and be the only option under the cost-effectiveness threshold. In summary, biennial screening for average-risk women aged 35-64 years is the most cost-effective approach strategy, aligning with The National Health Commission's screening program for cervical and breast cancer.

Clinical Behavior of Breast Cancer in Young BRCA Carriers and Prediagnostic Awareness of Germline BRCA Status

PURPOSE

To investigate the clinical behavior of breast cancer in young BRCA carriers according to the specific BRCA gene (BRCA1 v BRCA2) and the association of the timing of genetic testing (before v at diagnosis) with prognosis.

METHODS

This was an international, multicenter, hospital-based, retrospective cohort study that included 4,752 patients harboring germline pathogenic/likely pathogenic variants (PVs) in BRCA1 or BRCA2, who were diagnosed with stage I-III invasive breast cancer at 40 years or younger between January 2000 and December 2020 in 78 centers worldwide (ClinicalTrials.gov identifier: NCT03673306).

RESULTS

Compared with BRCA2 carriers (n = 1,683), BRCA1 carriers (n = 3,069) had more frequently hormone receptor-negative (74.4% v 15.5%) and high-grade (77.5% v 49.1%) tumors. Similar outcomes were observed in BRCA1 and BRCA2 carriers but with a different pattern and risk of disease-free survival events over time. Compared with patients tested for BRCA at diagnosis (ie, between 2 months before and up to 6 months after diagnosis; n = 1,671), those tested before diagnosis (ie, any time up to 2 months before diagnosis; n = 411) had smaller tumors (T1: 61.3% v 32.4%), less nodal involvement (N0: 65.9% v 50.8%), less frequently received chemotherapy (84.4% v 92.9%), and axillary dissection (37.5% v 47.4%). Patients tested before diagnosis had better overall survival (OS; unadjusted hazard ratio [HR], 0.61 [95% CI, 0.40 to 0.92]); however, this result lost statistical significance after adjustment for potential confounders including tumor stage (adjusted HR, 0.74 [95% CI, 0.47 to 1.15]).

CONCLUSION

This global study provides evidence on the different clinical behavior of breast cancer in young BRCA1 and BRCA2 carriers. Identifying a BRCA PV in healthy individuals was associated with earlier-stage breast cancer diagnosis and lower treatment burden, as well as better unadjusted OS.

Cancers Detected on Supplemental Breast Ultrasound in Women With Dense Breasts: Update From a Canadian Centre

Objective: Breast ultrasound is one of several tools proposed for supplemental screening of women with dense breasts but is not widely available in Canada. Methods: An IRB-approved, evaluation of ultrasound-guided breast biopsies prompted by screening breast ultrasound performed from August 1, 2021, to December 31, 2022, offered to asymptomatic women with category C and D breast tissue density after normal screening mammography (2D) in the provincial organized screening program, or surveillance diagnostic mammography after breast cancer. Risk factors, stage (AJCC 8th ed), incremental cancer detection rate (ICDR), biopsy rates, and positive predictive values for biopsy (PPV3) were evaluated. Results: 5257 women were screened, yielding 247 women (ages 34-82, median age of 56) who underwent biopsies (281 masses), 32 of whom were diagnosed with breast cancer, 27 invasive and 5 DCIS for PPV3 13.0% (32/247), and ICDR 6.1/1000. Ductal cancers found were stage 0 in 5/32 (15.6%), stage 1A in 18/32 (56.3%), and stage 1B in 2/32 (6.3%), 1 ductal/lobular cancer was stage 3B (3.1%), 5 lobular cancers (16.6%) were stage 1A (1), 1B (2), and 2B (2) and 1 adenoid cystic carcinoma was stage 2A (3.1%); 3 cancers were found on incident and 29 on prevalent screens, 27 (84.4%) in category c and 20 (62.5%) in women with no personal or first-degree family history of breast cancer. Conclusion: A high ICDR for screening breast ultrasound of 6.1/1000 was found. Clinical Relevance Statement: In women with dense breasts screened with 2D mammography where access to supplemental screening with MRI and contrast mammography is limited, supplemental screening ultrasound can play a significant role in cancer detection with a high ICDR in women in both category c and d densities that is higher than in jurisdictions offering annual screening mammography, or where MRI is used for surveillance after cancer.

National yearly cost of breast cancer screening in the USA and projected cost of advocated guidelines: a simulation study with life table modelling

OBJECTIVE

The aim of this study was to estimate the total national direct cost of breast cancer screening from 2019 to 2022 and project the total national cost and average lifetime cost of screening per woman for three current guidelines.

DESIGN

We estimated the national cost of screening from 2019 to 2022, and per cancer detected in 2022, using real-world data on the number of mammograms performed per year. We also projected the national cost of screening using life table modelling for three guidelines: 2021/2023 American College of Radiology (ACR), 2023 American Cancer Society (ACS) and 2024 United States Preventative Services Task Force (USPSTF). The average lifetime cost to screen one woman until age 74 years with each guideline was also estimated. The Optum Labs Data Warehouse was used to estimate commercial and Medicare costs and recall rates. Sensitivity analyses were used to estimate uncertainty and determine which inputs had the largest impact on total national costs.

SETTING

This study was conducted for the USA.

PARTICIPANTS

Women eligible for breast cancer screening.

INTERVENTIONS

Digital mammograms (2D) or digital breast tomosynthesis (3D) and/or MRI.

PRIMARY OUTCOME MEASURE

Total national cost of screening calculated as the sum of screening and recall costs. Average lifetime cost of screening per woman until 74 years.

RESULTS

Nationally, screening cost approximately US$11 billion (B) per year from 2019 to 2022 with approximately 37% of eligible women screened each year. In 2022, screening cost US$55 471 per 3D-detected and US$44 000 per 2D-detected invasive or ductal carcinoma in situ case. Using target yearly participation rates of 54%-78% by age of women, the projected cost of screening was US$30B for ACR, US$18B for ACS and US$8B for USPSTF guidelines. The average lifetime cost to screen an average-risk woman was: US$13 416 for ACR, US$7946 for ACS and US$6931 for USPSTF. Participation rates, the proportion of women with a lifetime risk>20% and commercial MRI and 3D costs had the largest impact on total costs.

CONCLUSION

The cost of screening varies significantly by guideline (US$8B-US$30B) and was most influenced by participation rates, high-risk population proportions and technology costs. Future work can investigate whether risk-based screening strategies being tested in ongoing clinical trials can reduce national screening costs while improving outcomes.Cite Now.

Risk factors for interval breast cancer: insights from a decade of a mammography screening program

PURPOSE

Breast cancer remains a major global health issue, with mammography screening programs (MSPs) being critical for early detection to improve survival. Interval breast cancers (IBC) are an important quality criterion and have been linked with increased mortality. We aimed to identify risk factors for IBC diagnoses, based on MSP data.

METHODS

In this retrospective cohort study, we merged data from the Swiss MSP "donna" with data from cancer registries from 2010 to 2019 to categorize cases as IBC or screen-detected breast cancer (SBC). We compared the incidence, tumor characteristics, and survival proportions of women with IBC versus SBC. We used a multivariable Poisson regression with robust errors to identify risk factors for IBC diagnoses.

RESULTS

We identified 1134 breast cancer cases, specifically 251 IBC and 883 SBC. The 7-year survival proportions significantly deviated with 92.9% for women with IBC and 96.4% for women with SBC (p < 0.05). Women with IBC are diagnosed with significantly higher tumor stages (p < 0.05) and have a worse tumor biology in multiple dimensions e.g. larger tumor size or more often triple negative (p < 0.05). Higher breast density (BI-RADS d risk ratio (RR): 3.293), certain age groups (55-59 years RR: 1.345), and a family breast cancer history (RR: 1.299) were identified as significant (p < 0.05) risk factors for IBC diagnoses.

CONCLUSIONS

Women with IBC had lower overall survival proportions than women with SBC, possibly due to higher stages at diagnosis. Increased breast density and a positive family history of breast cancer could encourage MSPs to personalize their screening process (e.g. additional diagnostics).

A review of gadolinium-based contrast agents in the setting of repeated MRI for high risk breast cancer screening

Women who are considered high risk for breast cancer are recommended to undergo supplemental breast cancer screening annually with MRI. There are primarily three safety concerns associated with gadolinium-based contrast agents which include allergic reactions, nephrogenic systemic fibrosis and gadolinium deposition. In this review, we discuss how these risks are affected by molecular structure, will specifically review the difference between the two commonly used agents, gadobutrol and gadoterate, and discuss the most recent FDA approved contrast agent on the market, gadopiclenol.

False-Negative Review from the Mammography Audit: Refining Breast Imaging Practice

Annual review of false-negative (FN) mammograms is a mandatory and critical component of the Mammography Quality Standards Act (MQSA) annual mammography audit. FN review can help hone reading skills and improve the ability to detect cancers at mammography. Subtle architectural distortion, asymmetries (seen only on one view), small lesions, lesions with probably benign appearance (circumscribed regular borders), isolated microcalcifications, and skin thickening are the most common mammographic findings when the malignancy is visible at retrospective review of FN mammograms. Most FN mammograms are not due to radiologist error. There are common and predictable settings in which FN mammograms occur. Patient factors associated with elevated FN mammograms include dense breasts, elevated lifetime risk of breast cancer, and personal history of breast cancer treated with lumpectomy and radiation therapy. About half of FN cancers are detected by supplemental screening examinations and half manifest clinically. The most common manifesting symptoms for interval cancers are a palpable abnormality, nipple discharge, and skin changes. Interval cancers can have more aggressive pathologic features and higher rates of node positivity. The FN review includes Breast Imaging Reporting and Data System (BI-RADS) 3 cases that develop a cancer diagnosis during surveillance. Nonbreast malignancies diagnosed as interval cancers (most commonly lymphoma and metastatic disease) do not need to be counted as FNs for audit purposes. The FN review and annual audit are confidential processes that protect patient and radiologist information while allowing meaningful quality control and improvement. Although FN mammograms are rare, review of these cases is a valuable educational tool. The slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2025.

Using AI to Select Women with Intermediate Breast Cancer Risk for Breast Screening with MRI

Background Combined mammography and MRI screening is not universally accessible for women with intermediate breast cancer risk due to limited MRI resources. Selecting women for MRI by assessing their mammogram may enable more resource-effective screening. Purpose To explore the feasibility of using a commercial artificial intelligence (AI) system at mammography to stratify women with intermediate risk for supplemental MRI or no MRI. Materials and Methods This retrospective study included consecutive women with intermediate risk screened with mammography and MRI between January 2003 and January 2020 at a Dutch university medical center. An AI system was used to independently evaluate all mammograms, providing a case-based score that ranked the likelihood of a malignancy on a scale of 1-10. Different AI thresholds for supplemental MRI screening were tested, balancing cancer detection against the number of women needing to undergo MRI. Univariate analyses were used to explore associations between personal factors (age, breast density, and duration of screening participation) and AI results. Results In 760 women (mean age, 48.9 years ± 10.5 [SD]), 2819 combined screening examinations were performed, and 37 breast cancers were detected. Use of AI at mammography achieved an area under the receiver operating characteristic curve of 0.72 (95% CI: 0.63, 0.81) for the entire intermediate-risk population and 0.81 (95% CI: 0.69, 0.93) for women with prior breast cancer. Using a threshold score of 5, 31 of 37 (84%) breast cancers were detected, including 13 of 19 (68%) mammographically occult cancers, at a supplemental breast MRI rate of 50% (1409 of 2819 examinations). No significant association between breast density or age and the probability of a false-negative AI result was found. Conclusion Using AI at mammography to select women for supplemental MRI effectively identified women with higher breast cancer risk in an intermediate-risk population, including women with mammographically occult cancers. AI selection of women with intermediate risk for supplemental MRI screening has the potential to reduce screening burden and costs, while maintaining a high cancer detection rate. © RSNA, 2025.

Society of Surgical Oncology Breast Disease Site Working Group Statement on Bilateral Risk-Reducing Mastectomy: Indications, Outcomes, and Risks

Bilateral risk-reducing mastectomy (BRRM) is the surgical removal of both breasts to reduce the risk of cancer. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, outcomes, and risks of BRRM to update the society's 2017 statement. We held a virtual meeting to outline key topics and conducted a literature search using PubMed to identify relevant articles. After literature review, recommendations were made according to group consensus. Individuals with a high lifetime risk of breast cancer due to pathogenic variants in high penetrance breast cancer-predisposition genes, early chest or breast radiation exposure, or a compelling family history should be counseled on the option of BRRM. However, BRRM is not recommended for most patients with high-risk lesions and may be contraindicated in patients who have other competing cancers and/or a high risk of surgical complications. BRRM effectively reduces the risk of breast cancer development, although the survival benefit is unclear. For patients with low-to-moderate breast cancer risk, alternative management strategies should be encouraged, including lifestyle modifications, high-risk screening, and risk-reducing medications. Discussions of BRRM should cover: (1) breast-cancer risk estimates; (2) the procedure's degree of risk reduction and impact on survival; (3) surgical techniques, potential surgical complications and long-term sequelae; and (4) alternatives to surgery. Surgeons should encourage shared and informed decision making with patients who have an elevated lifetime risk of developing breast cancer.

Invasive Lobular Carcinoma in the Screening Setting

Invasive lobular carcinoma (ILC) is the second-most common histologic subtype of breast cancer, constituting 5% to 15% of all breast cancers. It is characterized by an infiltrating growth pattern that may decrease detectability on mammography and US. The use of digital breast tomosynthesis (DBT) improves conspicuity of ILC, and sensitivity is 80% to 88% for ILC. Sensitivity of mammography is lower in dense breasts, and breast tomosynthesis has better sensitivity for ILC in dense breasts compared with digital mammography (DM). Screening US identifies additional ILCs even after DBT, with a supplemental cancer detection rate of 0 to 1.2 ILC per 1000 examinations. Thirteen percent of incremental cancers found by screening US are ILCs. Breast MRI has a sensitivity of 93% for ILC. Abbreviated breast MRI also has high sensitivity but may be limited due to delayed enhancement in ILC. Contrast-enhanced mammography has improved sensitivity for ILC compared with DM, with higher specificity than breast MRI. In summary, supplemental screening modalities increase detection of ILC, with MRI demonstrating the highest sensitivity.

Breast MRI to Screen Women With Extremely Dense Breasts

Women with extremely dense breasts are at a higher risk of breast cancer, and the sensitivity of mammography in this group is reduced due to the masking effect of overlapping tissue. This review examines supplemental screening methods to improve detection in this population, with a focus on MRI. Morphologic techniques offer limited benefits, digital breast tomosynthesis (DBT) shows inconsistent results, and ultrasound (US), while improving cancer detection rates (CDR), results in a higher rate of false positives. Functional imaging techniques show better performance, molecular breast imaging increases CDR but is limited in availability, and contrast-enhanced mammography is promising, with good results and as an accessible technique, but requires further validation. MRI, with sensitivity ranging from 81% to 100%, is the most supported modality. Despite strong evidence for MRI in this population, high costs, use of contrast, and longer scan times hinder widespread use. Abbreviated MRI protocols aim to overcome these barriers by reducing costs and scan duration. As personalized screening becomes a future focus, MRI remains the most effective option for women with extremely dense breasts. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 5.

Female healthcare undergraduates' scientific readiness for raising breast cancer awareness in Syrian conservative community

INTRODUCTION

Breast cancer is the most common and deadliest cancer in Syria, and early detection is crucial in managing it. This study aims to compare the knowledge levels of breast cancer risk factors, signs, and symptoms among female students in healthcare faculties (medicine, dentistry, and pharmacy) at Damascus University to identify existing disparities. The goal is to enhance breast cancer education and awareness across Syria by empowering healthcare students with insights.

METHODS

An online self-administered questionnaire was shared on social media for female students of healthcare faculties to respond to. A total of 589 participants were included after applying the inclusion criteria. The questionnaire collected sociodemographic characteristics and evaluated the knowledge of breast cancer (BC) using breast cancer awareness measure (BCAM). The scale evaluates three sections: general knowledge, symptoms, and risk factors. Comparisons were conducted among the three faculties to gauge variations in knowledge levels.

RESULTS

The majority of participants were aged between 21-23, the average of breast cancer knowledge among the whole sample was 24.7 ± 6.33 out of 40, with the internet and social media being the primary sources of information. Medical students had significantly higher knowledge scores compared to pharmacy and dentistry students. Higher faculty average grades were associated with higher knowledge scores, and there was a positive correlation between study years and breast cancer knowledge for medical and pharmacy students. There was no significant difference in breast cancer knowledge between participants with and without a medical relative or family history of breast cancer.

CONCLUSION

Breast cancer knowledge among female healthcare students in Damascus University is perfectible, which may not be enough to raise awareness. Awareness programs should be created to encourage leadership and accurate information dissemination, and professors should model good prevention practices.

Patient perspective: Is intensive screening of women at high risk of breast cancer evidence-based medicine or déjà vu?

In 2023, a breast cancer risk assessment and a subsequent positive test for the BRCA-2 genetic mutation brought me to the uncomfortable intersection of a longstanding career as an advocate for high-quality medical evidence to support shared patient-provider decision making and a new role as a high-risk patient. My search for studies of available risk-management options revealed that the most commonly recommended approach for women with a ⩾20% lifetime breast cancer risk, intensive screening including annual mammography and/or magnetic resonance imaging beginning at age 25-40 years, was supported only by cancer-detection statistics, with almost no evidence on patient-centered outcomes-mortality, physical and psychological morbidity, or quality of life-compared with standard screening or a surgical alternative, bilateral risk-reducing mastectomy. In this commentary, I explore parallels between the use of the intensive screening protocol and another longstanding women's health recommendation based on limited evidence, the use of hormone therapy (HT) for postmenopausal chronic disease prevention, which was sharply curtailed after the publication of the groundbreaking Women's Health Initiative trial in 2002. These declines in HT utilization were followed by marked decreases in breast cancer incidence, providing a compelling lesson on the critical importance of a solid evidentiary basis for women's health decisions. Known harms accompanying the benefits of breast screening-overdiagnosis, psychological effects, and mammography-associated radiation-exposure risks-make empirical measurement of patient-centered outcomes essential. Yet, published research on intensive screening of women at high breast cancer risk has largely ignored these outcomes, leaving patients, providers, and guideline developers lacking the evidence needed for best practice. Outcomes research is both feasible and urgently needed to inform care decisions and health policy for this patient population.

Breast Imaging: what women & healthcare professionals need to know

Women in Radiology should be aware of the importance of early detection of breast cancer, the most common cancer in women. This knowledge is essential to advocate for high quality breast imaging for women, including themselves and their patients. The imaging modalities used in breast imaging have dramatically changed the way in which breast cancer may be diagnosed, and their use affects the stage at which it is diagnosed. Breast cancer may be screen-detected, either with mammography, digital breast tomosynthesis, breast ultrasound, breast MRI or contrast-enhanced mammography, and is typically diagnosed at stage 1. Incidental detection with Chest CT, abdominal CT or MRI or by PET CT may also lead to a diagnosis of breast cancer. When detected because of symptoms in women who have not undergone routine screening or as an interval cancer in women after a normal screen typically because of the masking effect of dense breast tissue, breast cancer is typically diagnosed at a more advanced stage, stage IIA or greater. A review of the imaging modalities currently used to diagnose breast cancer is provided and includes the advantages and limitations of each modality and the ways to optimize the imaging quality for detection of breast cancer. Up-to-date recommendations aimed to minimize the harms of delayed diagnosis of breast cancer are summarized to improve the health of women in Radiology and their patients.

Extremely dense breasts: A comprehensive review of increased cancer risk and supplementary screening methods

Women with extremely dense breasts account for approximately 10% of the screening population and face an increased lifetime risk of developing breast cancer. At the same time, the sensitivity of mammography, the first-line screening modality, is significantly reduced in this breast density group, owing to the masking effect of the abundant fibroglandular tissue. Consequently, this population has garnered increasing scientific attention due to the unique diagnostic challenge they present. Several research initiatives have attempted to address this diagnostic challenge by incorporating supplemental imaging modalities such as ultrasound, MRI, and contrast-enhanced mammography. Each of these modalities offers different benefits as well as limitations, both clinically and practically, including considerations of availability and costs. The purpose of this article is to critically review the background, latest scientific evidence, and future directions for the use of the various supplemental screening techniques for women with extremely dense breasts.

Level of Awareness, Screening Practices, and Self-Detection Among Breast Cancer Patients

Objective

Having good knowledge and performing regular pre-tests under physician supervision play a crucial role in the early detection of breast cancer. The aim of this study was to investigate the level of awareness, frequency of performing routine screening, types of screening methods prior to detection, and who detected the case, among women diagnosed with breast cancer.

Materials and Methods

A cross-sectional study that used a designed questionnaire applied to investigate demographic data and four other aspects: level of awareness, screening practices, type of screening methods used, and who detected the case for the first time. Women who were diagnosed with breast cancer and registered at Nanakali Hospital were included.

Results

A total of 150 women participated. Most of the participants (80%) had no previous knowledge regarding causes, signs and symptoms, or detection methods, while only 20% had little information. Among the participants, most (87.3%) did not undergo any pre-tests before the time of diagnosis, while only 12.7% did pre-test at least once. The screening methods used prior to the diagnosis were: breast self-exam (n=9); ultrasonography (n=8), and only two had mammography. Detecting the case for the first time, 68.7% of the cases were detected by chance or accidentally, and 31.3% were detected by physicians.

Conclusion

The level of awareness and performance of routine screening differ greatly among different populations and countries. Women in Erbil, generally have a low level of awareness and insufficient knowledge regarding breast cancer; most women do not undertake any regular screening for early detection of this cancer compared to Western countries. Having previous knowledge and doing pre-tests regularly play a key role in the early detection of this cancer, which minimizes the consequences.

Barriers and facilitators to breast cancer screening among high-risk women: a qualitative study

PURPOSE

Women with greater than 20-25% lifetime breast cancer risk are recommended to have breast cancer screening with annual mammogram and supplemental breast MRI. However, few women follow these screening recommendations. The objective of this study was to identify barriers and facilitators of screening among women at high risk for breast cancer, guided by the Health Services Utilization Model (HSUM).

METHODS

Unaffected high-risk women (N=63) completed semi-structured qualitative interviews exploring their experiences with breast cancer screening. Interviews were audio recorded, transcribed verbatim, and analyzed using a combined deductive and inductive approach.

RESULTS

Most participants (84%) had received a screening mammogram; fewer (33%) had received a screening breast MRI. Only 14% had received neither screening. In line with the HSUM, qualitative analysis identified predisposing factors, enabling factors, and need factors associated with receipt of breast cancer screening. Enabling factors - including financial burden, logistic barriers, social support, and care coordination - were most frequently discussed. Predisposing factors included knowledge, health beliefs, and self-advocacy. Need factors included healthcare provider recommendation, family history of breast cancer, and personal medical history. Although HSUM themes were consistent for both mammography and breast MRI, participants did highlight several important differences in barriers and facilitators between the two screening modalities.

CONCLUSION

Barriers and enabling factors associated with supplemental screening for high-risk women represent possible intervention targets. Future research is needed to develop and test multilevel interventions targeting these factors, with the ultimate goal of increasing access to supplemental screening for high-risk women.

Surveillance Breast MRI in Women with a History of Breast Cancer: Association with Occurrence of Advanced Second Breast Cancer

Background Studies on the association between surveillance breast MRI in women with a personal history of breast cancer (PHBC) and advanced second breast cancer are lacking. Purpose To investigate the association between postoperative surveillance breast MRI and advanced second breast cancer in women with a PHBC by using propensity score matching (PSM). Materials and Methods Women who underwent breast cancer surgery between January 2009 and December 2014 were retrospectively identified at a single tertiary center. Second breast cancer was defined as ipsilateral or contralateral breast cancer diagnosed at least 1 year after surgery, and advanced second breast cancer was defined as second breast cancer (a) grade T2 or higher or lymph node-positive or (b) T1c triple-negative or human epidermal growth factor receptor 2-positive. Women who underwent surveillance MRI and those who did not were matched using propensity scores according to 13 clinical-pathologic characteristics. Outcomes were compared using logistic regression analysis. Results Among the 3688 women (mean age, 51.1 years ± 10.5 [SD]), 2130 underwent surveillance MRI (MRI group) and 1558 did not (non-MRI group); 1062 patient pairs were matched. Advanced second breast cancer proportions for non-MRI and MRI groups were 1.7% (27 of 1558 participants) and 0.4% (eight of 2130 participants) before PSM and 1.6% (17 of 1062 participants) and 0.7% (seven of 1062) after PSM. Surveillance MRI was associated with lower odds of advanced second breast cancer before PSM (odds ratio [OR], 0.21 [95% CI: 0.10, 0.47]; P < .001) and after PSM (OR, 0.41 [95% CI: 0.17, 0.99]; P = .048). The proportion of symptomatic second breast cancers was higher in the non-MRI group before PSM (25% [16 of 65 second cancers] vs 6.4% [three of 47]; P = .01) and after PSM (21% [10 of 48] vs 3.2% [one of 31]; P = .003). Conclusion In women with a PHBC, MRI surveillance was associated with lower odds of advanced second breast cancer before and after PSM. © RSNA, 2025 Supplemental material is available for this article.

Mammographically Occult Breast Cancer in a Patient With Dense Breast Tissue

Routine screening mammography can decrease the mortality from breast cancer by early detection. Dense breast tissue limits the detection of cancer with mammography alone, and the use of supplemental imaging to improve early detection is necessary in these patients. For women with dense breasts who would benefit from supplemental screening, modalities, such as MRI, whole breast ultrasound, contrast-enhanced mammography, and molecular breast imaging, are available to aid in the detection of mammographically occult cancers.

Risk-based breast cancer screening: What are the challenges?

Population-based screening programs aim to detect the disease at an early stage, so less treatment will be needed as well as having better oncological outcomes when diagnosed earlier. In the majority of European countries, breast cancer screening programs are designed based on women age.Meta-analysis of randomized clinical trial data demonstrates a reduction in the relative risk of breast cancer mortality due to screening, which has been estimated to be approximately 20%.One of the controversies about the population breast screening programs is that age-based screening ignores women's individual breast cancer risk. Identification of high-risk women may intensify the screening measures and will optimize the population screening programs to align them to individual risks.Family history of breast cancer is one of the risk factors to consider along with the recently developed polygenic risk scores to stratify women into a risk group. Other factors to assess risk include: mammographic breast density; B3 lesions with atypia in breast biopsy specimens; hormonal and lyfestyle and, potentially, epigenetic markers. Still, there are some difficulties in validating these factors and reflecting the interaction between risk factors in the models.Ongoing screening trials (e.g., WISDOM and MyPebs) are currently evaluating the clinical acceptability and utility of risk-stratified screening programs in the general population, and should provide valuable information for the possible implementation of such programs.Communication of complex risk information to the women, as well as assessing ethical concerns need to be addressed before implementation of risk stratified programs.

Differential Access to Breast Magnetic Resonance Imaging Compared with Mammography and Ultrasound

INTRODUCTION

For high-risk women, breast magnetic resonance (MR) is the preferred supplemental imaging option, but spatial access differences may exacerbate disparities in breast care.

METHODS

This was a cross-sectional study examining distance between ZIP codes and the nearest breast imaging facility (MR, mammography, ultrasound) using 2023 data from the Food and Drug Administration and the American College of Radiology. Linear regression was used to assess distance differences controlling for Area Deprivation Index (ADI), urbanicity, and population size. Analyses were conducted in 2024.

RESULTS

Among the 29,629 ZIP codes with an ADI and known urbanicity, unadjusted mean distance to breast MR was 23.2±25.1 miles (SD) compared with 8.2±8.3 for mammography and 22.2±25.0 for ultrasound. Hence, the average distance to breast MR facilities was 2.8 times further than to mammography facilities. ADI and urbanicity were associated with increased distance to the nearest breast imaging facility. The additional miles associated with the least advantaged areas compared with most advantaged areas was 12.2 (95%CI: 11.3, 13.2) for MR, 11.5 miles (95%CI: 10.6, 12.3) for ultrasound, and 2.4 (95%CI: 2.1, 2.7) for mammography. Compared with metropolitan areas, the additional miles to breast MR facilities was 23.2 (95%CI: 22.5, 24.0) for small/rural areas.

CONCLUSIONS

Spatial access is substantially better for mammography sites compared with breast MR or ultrasound sites. Given these findings, consideration of options to mitigate the impact of differential access should be considered. For example, mammography sites could offer contrast-enhanced mammography. Future research should examine the feasibility and effectiveness of this and other options.

A Retrospective Chart Analysis Comparing Breast Cancer Detection Rates Between Annual Versus Biennial Mammograms

Background

Per American Cancer Society, breast cancer is one of the most prevalent causes of cancer-related mortality in women in the United States. Different organizations vary in their recommendations regarding frequency of mammograms, with the United State Preventive Service Taskforce recommending biennial screening and other organizations like American College of Radiology promoting annual screening. The purpose of this study was to analyze institutional data to compare breast cancer detection rates among women undergoing annual vs. biennial mammograms.

Methods

In this retrospective chart review, we analyzed deidentified records of women aged 25 to 74 at Northeast Georgia Health System, who had undergone at least two screening mammograms and were diagnosed with primary breast cancer. We analyzed several variables including Breast Imaging Reporting and Data System (BI-RADS) categorization, estrogen receptor (ER) status, progesterone receptor (PR) status, human epidermal growth factor receptor 2 (HER2) status, age, race, ethnicity, nodal involvement, smoking status, insurance status, grade, tumor size, number of screening mammograms, personal history of breast cancer, family history of breast cancer, and their correlation to screening frequency (annual vs. biennial vs. less than biennial).

Results

Among the total 2,219 records that satisfied the inclusion criteria, we observed that BI-RADS categorization (P < 0.001), ER status (P = 0.003), and PR status (P = 0.001) were associated with mammogram screening frequency while the other variables were not statistically significant. Post-hoc analysis revealed that biennially screened patients exhibited less N2 node involvement than expected (P = 0.022). Additionally, Hispanic/Latino(a) patients had a greater frequency of biennial screenings than expected (P = 0.050). Lastly, post-hoc analysis revealed that current smokers had a greater incidence of less-frequent-than-biennial screenings (P = 0.023).

Conclusions

Annual mammograms were associated with a lower BI-RADS stage and lower stage of breast cancer diagnosis.

Contemporary Review of the Management and Treatment of Young Breast Cancer Patients

Approximately 11% of all new breast cancer cases annually are diagnosed in young women, and this continues to be the leading cause of death in women age 20 to 49. Young, premenopausal breast cancer patients present with more advanced stages and with a higher proportion of aggressive subtypes such as triple negative and HER2-enriched tumors. Recently, the United States Preventive Services Task Force (USPSTF) lowered the age threshold to initiate screening mammograms to age 40 to aid in earlier detection. Young age at diagnosis increases the likelihood for a pathogenic mutation, and genetic testing is recommended for all patients age 50 and younger. This population is often underrepresented in landmark clinical trials, and data is extrapolated for the treatment of young women with breast cancer. Despite there being no survival benefit to more extensive surgical treatments, such as mastectomy or contralateral prophylactic mastectomy, many patients opt against breast conservation. Young patients with breast cancer face issues related to treatment toxicities, potential overtreatment of their disease, mental health, sexual health, and fertility preservation. This unique population requires a multidisciplinary care team of physicians, surgeons, genetic counselors, fertility specialists, mental health professionals, physical therapists, and dieticians to provide individualized, comprehensive care. Our aim is to (1) provide a narrative review of retrospective studies, relevant society guidelines, and clinical trials focused on the contemporary treatment and management of YBC patients and (2) discuss important nuances in their care as a guide for members of their multidisciplinary treatment team.

Clinical experience on the limited role of ultrasound for breast cancer screening in BRCA1 and BRCA2 mutations carriers aged 30-39 years

PURPOSE

In BRCA germline pathogenic sequence variants (PSV) carriers aged 30-39 years imaging is recommended at six-month intervals. The European society for medical oncology recommendation of the use of 6-monthly MRI six-monthly MRI screening is being considered at our institution, particularly for younger carriers under the age of 35, although it is not mandatory. If 6-monthly MRI is unavailable, annual MRI may be supplemented by ultrasound (with or without mammography). The aim of this study was to evaluate the utility of ultrasound screening added to mammography, as a 6-month supplement to annual MRI in BRCA PSV carriers aged 30-39 years.

MATERIALS AND METHODS

This IRB approved retrospective study included BRCA PSV carriers aged 30-39 years, who underwent breast cancer screening at our institution between January 2015 and March 2023. Participants were divided into two groups, those who had supplemental whole-breast US and mammography at six months and underwent screening before March 2019, and those who had only mammography without supplemental US and enrolled in screening after March 2019. Patient characteristics, cancer detection rates and cancer characteristics were compared between the two groups.

RESULTS

Overall, 200 asymptomatic BRCA1/2 PSV carriers undergoing screening in our institution were included in the study. Mean age was 35.7 ± 3.5 years, and mean follow-up time was 37.4 ± 38.0 months. There were 118 (59 %) women screened with supplemental US, and 82 (41 %) women without. Eight cancers were diagnosed during the study period, four in women with supplemental US and four in women without. The sensitivity of whole-breast screening US was 25 % (1/4), specificity 85.7 % (222/259), PPV 2.6 % (1/38), and NPV 98.7 % (222/225). Of the four cancers detected in women screened with supplemental US, one was diagnosed by whole-breast US, two by MRI, and one by mammography. Of eight cancers included in this study, two were not detectable by targeted second-look US. All eight cancers were detectable by MRI.

CONCLUSION

The addition of whole-breast ultrasound to mammography and MRI screening in BRCA PSV carriers aged 30-39 years offered limited incremental benefit. MRI with 6 months supplemental mammography without US detected all cancer cases.

Performance of Abbreviated Breast MRI in High-Risk Patients in a Tertiary Care Academic Medical Center

INTRODUCTION

The development of abbreviated breast MRI (AB-MRI) protocols reduce scan times. This paper reports the performance of AB-MRI at a tertiary care public academic medical center in comparison with established literature.

METHODS

This HIPAA-compliant IRB-approved retrospective study reviewed 413 AB-MRI screenings in high-risk patients from June 2020 to March 2023. Data were collected from 3 databases (MagView, Cerner PowerChart, and Prism Primordial). Demographics and overall BI-RADS assessment were recorded. For all positive (BI-RADS 0, 3, 4, 5) examinations, manual review of each case was performed. Performance metrics (sensitivity, specificity, cancer detection rate [CDR], recall rate, positive predictive value [PPV] 3 and negative predictive value [NPV]) were calculated. PubMed and Google Scholar were used to review similar AB-MRI studies to compare performance metrics.

RESULTS

There were 413 AB-MRI examinations from 413 unique patients. The majority of cases were audit-negative BI-RADS 1 or 2 (83.8%, 346/413). There were 67 (16.2%, 67/413) audit-positive cases with 3.6% (15/413) BI-RADS 3, 10.9% (45/413) BI-RADS 4, 0.7% (3/413) BI-RADS 5, and 1.0% (4/413) BI-RADS 0. Performance metrics showed a sensitivity of 100.0% (95% CI, 63.1%-100.0%) and a specificity of 85.7% (95% CI, 81.9%-88.9%). The PPV3 was 14.3% (95% CI, 5.1%-23.5%), and the NPV was 100.0% (95% CI, 99.0%-100.0%). The CDR was 19.4 per 1000 screenings. The results are comparable to prior literature and benchmark data.

CONCLUSION

This study demonstrates high sensitivity (100.0%) and NPV (100.0%) of AB-MRI with comparable specificity (85.7%) and CDR (19.4/1000) to the literature, adding support to the use of AB-MRI. Further research is needed to optimize AB-MRI protocols.

Prospective Study of Supplemental Screening With Contrast-Enhanced Mammography in Women With Elevated Risk of Breast Cancer: Results of the Prevalence Round

PURPOSE

Contrast-enhanced mammography (CEM) and magnetic resonance imaging (MRI) have shown similar diagnostic performance in detection of breast cancer. Limited CEM data are available for high-risk breast cancer screening. The purpose of the study was to prospectively investigate the efficacy of supplemental screening CEM in elevated risk patients.

MATERIALS AND METHODS

A prospective, single-institution, institutional review board-approved observational study was conducted in asymptomatic elevated risk women age 35 years or older who had a negative conventional two-dimensional digital breast tomosynthesis screening mammography (MG) and no additional supplemental screening within the prior 12 months.

RESULTS

Four hundred sixty women were enrolled from February 2019 to April 2021. The median age was 56.8 (range, 35.0-79.2) years; 408 of 460 (88.7%) were mammographically dense. Biopsy revealed benign changes in 22 women (22/37, 59%), high-risk lesions in four women (4/37, 11%), and breast cancer in 11 women (11/37, 30%). Fourteen cancers (10 invasive, tumor size range 4-15 mm, median 9 mm) were diagnosed in 11 women. The overall supplemental cancer detection rate was 23.9 per 1,000 patients, 95% CI (12.0 to 42.4). All cancers were grade 1 or 2, ER+ ERBB2-, and node negative. CEM imaging screening offered high specificity (0.875 [95% CI, 0.844 to 0.906]), high NPV (0.998 [95% CI, 0.993 to 1.000), moderate PPV1 (0.164 [95% CI, 0.076 to 0.253), moderate PPV3 (0.275 [95% CI, 0.137 to 0.413]), and high sensitivity (0.917 [95% CI, 0.760 to 1.000]). At least 1 year of imaging follow-up was available on all patients, and one interval cancer was detected on breast MRI 4 months after negative screening CEM.

CONCLUSION

A pilot trial demonstrates a supplemental cancer detection rate of 23.9 per 1,000 in women at an elevated risk for breast cancer. Larger, multi-institutional, multiyear CEM trials in patients at elevated risk are needed for validation.

Survey on Current Utilization and Perception of Synthesized Mammography

OBJECTIVE

To assess utilization and perceptions of 2D synthesized mammography (SM) for digital breast tomosynthesis (DBT) among practicing U.S. breast radiologists.

METHODS

An IRB-exempt 23-question anonymized survey was developed by the Society of Breast Imaging (SBI) Patient Care and Delivery Committee and emailed to practicing U.S. radiologist SBI members on October 9, 2023. Questions assessed respondents' demographics, current mammographic screening protocol, confidence interpreting SM for mammographic findings, and perceived advantages and disadvantages of SM.

RESULTS

Response rate was 13.4% (371/2771). Of 371 respondents, 208 were currently screening with DBT/SM (56.1%), 98 with DBT/SM/digital mammography (DM) (26.4%), 61 with DBT/DM (16.4%), and 4 with DM (1.1%). Most respondents felt confident using DBT/SM to evaluate masses (254/319, 79.6%), asymmetries (247/319, 77.4%), and distortions (265/318, 83.3%); however, confidence was mixed for calcifications (agreement 130/320, 40.6%; disagreement 156/320, 48.8%; neutral 34/320, 10.6%). The most frequently cited disadvantage and advantage of SM were reconstruction algorithm false-positive results (199/347, 57.4%) and lower radiation dose (281/346, 81.2%), respectively. Higher confidence and fewer disadvantages were reported by radiologists who had more SM experience, screened with DBT/SM, or exclusively used Hologic vendor (all P <.05).

CONCLUSION

For most survey respondents (56.1%), SM has replaced DM in DBT screening. Radiologists currently screening with DBT/SM or with more SM experience reported greater confidence in SM with fewer perceived disadvantages.

Screening for Breast Cancer Risk: An Analysis of Under-recognized Risk Factors and Comparison of Interventions

Recognition of patients at high risk (HR) for breast cancer allows earlier screening and opportunities for risk reduction. We compare patients referred to our breast clinic as HR vs referrals for other reason (ROR) and found to be HR. We evaluate under-recognized factors and treatment differences. A retrospective chart review of patients found to be HR but referred for any reason to our breast clinic from July 2012 to December 2022 was performed. Referral reason, demographics, hormonal history, family history, and other risk factors were evaluated and compared (HR vs ROR). While other risk models were used for screening, Gail and Tyrer-Cuzick version 7 (TCv7) were used for comparison. Breast imaging received, hormonal therapy, and genetics referral evaluations were compared. 195 patients were referred to our breast team, 113 (58%) were referred as HR while 82 (42%) were ROR. Average age was 47 years old. 175 (91%) were Caucasian. 74 (65.5%) were referred for genetic testing, and 32 (26%) tested positive for a genetic mutation (n = 10, 12% ROR). 67 (35%) were recommended chemoprevention (n = 32, 16.4% took chemoprevention). 6 (3.1%) underwent prophylactic mastectomies and 163 (85%) had supplemental breast imaging. Comparison of HR vs ROR did not show significant differences in hormonal factors or treatments received; however, TCv7 was higher in the group referred as HR (P < .001). Our study showed that HR patients are more commonly referred secondary to family history but undergo similar treatments as those ROR. Accessibility to screening tools and education of risk factors, especially in minorities and those not otherwise being screened, may help better recognize HR.

Relative Timing of Mammography and MRI for Breast Cancer Screening: Impact on Performance Evaluation

OBJECTIVE

Mammography and MRI screening typically occur in combination or in alternating sequence. We compared multimodality screening performance accounting for the relative timing of mammography and MRI and overlapping follow-up periods.

METHODS

We identified 8,260 screening mammograms performed 2005 to 2017 in the Breast Cancer Surveillance Consortium, paired with screening MRIs within ±90 days (combined screening) or 91 to 270 days (alternating screening). Performance for combined screening (cancer detection rate [CDR] per 1,000 examinations and sensitivity) was calculated with 1-year follow-up for each modality, and with a single follow-up period treating the two tests as a single test. Alternating screening performance was calculated with 1-year follow-up for each modality and also with follow-up ending at the next screen if within 1 year (truncated follow-up).

RESULTS

For 3,810 combined screening pairs, CDR per 1,000 screens was 6.8 (95% confidence interval [CI]: 4.6-10.0) for mammography and 12.3 (95% CI: 9.3-16.4) for MRI as separate tests compared with 13.1 (95% CI: 10.0-17.3) as a single combined test. Sensitivity of each test was 48.1% (35.0%-61.5%) for mammography and 79.7% (95% CI: 67.7%-88.0%) for MRI compared with 96.2% (95% CI: 85.9%-99.0%) for combined screening. For 4,450 alternating screening pairs, mammography CDR per 1,000 screens changed from 3.6 (95% CI: 2.2-5.9) to zero with truncated follow-up; sensitivity was incalculable (denominator = 0). MRI CDR per 1,000 screens changed from 12.1 (95% CI 9.3-15.8) to 11.7 (95% CI: 8.9-15.3) with truncated follow-up; sensitivity changed from 75.0% (95% CI 63.8%-83.6%) to 86.7% (95% CI 75.5%-93.2%).

DISCUSSION

Updating auditing approaches to account for combined and alternating screening sequencing and to address outcome attribution issues arising from overlapping follow-up periods can improve the accuracy of multimodality screening performance evaluation.

Current State of Evidence-Based Long-Term Monitoring Protocols for Breast Plastic Surgery Patients

BACKGROUND

Recommendations for breast surveillance following breast plastic surgery are frequently changing. Establishing guidelines for long-term monitoring protocols may help identify treatable conditions and prevent untoward sequelae. We sought to evaluate the current state of evidence-based long-term monitoring protocols for patients following breast augmentation, reduction, and breast reconstruction.

METHODS

Official guidelines from various American societies and international societies were analyzed for alignment in evidence-based recommendations regarding breast surveillance.

RESULTS

The most recent US FDA update recommends magnetic resonance imaging or ultrasound starting 5-6 years after surgery and every 2-3 years thereafter. Discrepancies exist among professional societies: the American Society of Plastic Surgeons (ASPS) aligns with the FDA, while the American Society of Breast Surgeons and American College of Radiology (ACR) find no role for imaging for asymptomatic cases. Ultrasound is first-line for any implant concerns, with MRI if necessary. European societies oppose routine breast implant imaging. Breast reduction patients lack unique screening protocols; monitoring aligns with age and cancer risk factors. Following mastectomy and breast reconstruction, most organizations advocate for annual clinical examinations, with more frequent examinations initially. Evidence suggests that physical examination is sufficient to detect local cancer recurrence, with imaging only indicated if there is concern for recurrence. No surveillance imaging is recommended by the American Society of Clinical Oncology, National Comprehensive Cancer Network, or ASPS; however, ACR recommends mammography for autologous reconstruction only.

CONCLUSION

Multispecialty and regulatory body alignment may promote provider and patient adherence. Ongoing studies of long-term outcomes are needed to strengthen the level of evidence for monitoring guidelines.

Clinical guidelines for the management of mammographic density: a systematic review of breast screening guidelines worldwide

BACKGROUND

High breast density is an independent risk factor for breast cancer and decreases the sensitivity of mammography. This systematic review synthesizes the international clinical guidelines and the evidence base for screening and supplemental screening recommendations in women with dense breasts.

METHODS

A systematic search of CINHAL, Embase, and Medline databases was performed in August 2023 and grey literature searched in January 2024. Two authors independently assessed study eligibility and quality (Appraisal of Guidelines for Research and Evaluation II instrument).

RESULTS

Of 3809 articles, 23 guidelines published from 2014 to 2024 were included. The content and quality varied between the guidelines; the average AGREE II total score was 58% (range = 23%-87%). Most guidelines recommended annual or biennial screening mammography for women more than 40 years old with dense breasts (n = 16). Other guidelines recommended breast tomosynthesis (DBT, n = 6) or magnetic resonance imaging (MRI, n = 1) as the preferred screening modality. One third of the guidelines (n = 8) did not recommend supplemental screening for women with dense breasts. Of those that recommended supplemental screening (n = 14), ultrasound was the preferred modality (n = 7), with MRI (n = 3), DBT (n = 3), and contrast-enhanced mammography (n = 2) also recommended.

CONCLUSIONS

Consensus on supplemental screening in women with dense breasts is lacking. The quality of the guidelines is variable, and recommendations are based largely on low-quality evidence. As evidence of the benefits versus harms of supplemental screening in women with dense breasts is evolving, it is imperative to improve the methodological quality of breast cancer screening and supplemental screening guidelines.

Updates in Breast Cancer Screening and Diagnosis

OPINION STATEMENT

Breast cancer does not wait until a woman reaches her 50's to strike. One in six cases occurs in women between the ages of 40 and 49 and breast cancer is the most prevalent cancer and the leading cause of cancer-related deaths among women under 50 in the United States (10% of breast cancer deaths), emphasizing the urgency of early detection (American Society. 2024). Duffy et al. highlight the vital role of mammography screening in younger women, showing that starting screening at 40 reduces breast cancer mortality, with a consistent absolute reduction over time (Duffy et al. Health Technol Assess. 24(55):1-24, 2020). By starting yearly mammograms at 40, we could see a remarkable 40% reduction in breast cancer deaths (Monticciolo et al. J Am Coll Radiol. 18(9):1280-8, 2021). Screening at age 40 also adds little to the burden of overdiagnosis that already arises from screening at age 50 and older. Comparing this to biennial screening between ages 50-74, yearly screening at 40 saves approximately 13,770 more lives annually according to a report by the American Cancer Society published in JAMA in 2015 (Oeffinger et al. JAMA. 314(15):1599-614, 2015). But it's not just about saving lives; it's also about preserving quality of life. Between ages 40 and 49, 12-15% of years of life lost are attributed to breast cancer, highlighting the impact on women's lives. Early detection through screening can minimize these losses, ensuring more years spent with loved ones. It's clear: starting mammograms at age 40 saves lives. We must prioritize early detection and make screening accessible to all women, regardless of age. This proactive approach can reduce the burden of breast cancer and pave the way for a healthier future for women everywhere.

Performance of breast MRI for high-risk screening during lactation

OBJECTIVES

To assess the diagnostic performance of breast MRI during lactation in the setting of high-risk breast cancer screening.

MATERIALS AND METHODS

Screening breast MRIs performed between April 2008 and March 2024 were retrospectively reviewed. Background parenchymal enhancement (BPE) grade was compared between lactating patients and patients who recently stopped lactating using the Mann-Whitney test. Breast Imaging Reporting and Data System (BI-RADS) scores prevalence rates were compared between lactating patients and controls encompassing young non-lactating patients using the Chi-square test. Diagnostic performance was calculated for patients with a biopsy reference or a 1-year radiologic follow-up.

RESULTS

One-hundred forty-two screening breast MRIs were performed in lactating patients (n = 104, median age, 36.0 ± 6.0 years). Marked BPE appeared in 82% of cases (116/142), with a higher BPE grade in exams performed during lactation as compared with those performed in patients who had recently ceased lactating (p < 0.001). Screening MRIs performed during lactation had a higher rate of BI-RADS 3 scores (40/142, 28% vs. 683/8922, 7%, p < 0.001) and a lower rate of BI-RADS 1/2 scores (88/142, 62% vs. 7549/8922, 84.6%, p = 0.002) compared with those performed in controls (n = 8922). One pregnancy-associated breast cancer was detected, and one interval-cancer occurred. All MRI-guided biopsies were negative (n = 13). Screening breast MRI during lactation had 50% sensitivity (1/2), 60% specificity (72/120), 2.0% positive predictive value (1/49), and 98.6% negative predictive value (71/82).

CONCLUSION

The efficacy of breast MRI for high-risk screening during lactation is limited by prominent BPE, leading to an increased rate of BI-RADS 3 categorization and diminished overall specificity.

KEY POINTS

Question Studies on breast MRI during lactation were solely focused on studies conducted in patients with known cancer but not in the screening setting. Findings Screening breast MRI during lactation usually results in marked background parenchymal enhancement, negatively impacting its diagnostic performance. Clinical relevance Despite the lower performance, and amidst the significant risk of pregnancy-associated breast cancer, this screening approach remains relevant for lactating patients with high-risk profiles, such as BReast Cancer (BRCA) carriers. Radiologists should be familiar with the normal appearance of breast MRI during lactation.

Evaluating ten years of breast cancer screening with contrast enhanced mammography in women with Intermediate-high risk

PURPOSE

While mammography is considered the gold standard for screening women for breast cancer, its accuracy declines in women with dense breasts. The purpose of the study is to evaluate the diagnostic accuracy of contrast enhanced mammography (CEM) for detecting breast cancer in intermediate and high-risk women, including those with genetic predispositions, over a decade-long cohort at a tertiary center.

METHODS

We retrospectively analyzed all CEM examinations performed for screening purposes at a tertiary center between 2012 and 2023. Data were extracted from imaging reports and from medical records. All biopsies performed up to one year following CEM examinations, and all breast cancer cases were extracted. BI-RADS scores from CEM reports were compared to biopsy results and to imaging follow-up. Sensitivity, specificity, positive and negative predictive values, area under the ROC curve (AUC), and cumulative cancer detection rate were calculated.

RESULTS

Overall 5,424 screening CEM examinations were analyzed. The mean age was 54.8 ± 8.9 years. Family history of breast cancer was recorded in 1,134/5,424 (20.9 %) women. Most women (4,606/5,424, 84.9 %) had dense breasts (BI-RADS C-D). Overall, 628 biopsies were performed within one year of screening, and 74 cancers were detected. CEM had sensitivity 95.9 % (71/74), specificity 81.8 % (4378/5350), positive predictive value 6.8 % (71/1043), negative predictive value 99.9 % (4378/4381). The cancer detection rate for CEM was 13.1 per 1,000 cases, and the AUC was 0.923.

CONCLUSIONS

CEM is a viable breast cancer screening method for women with dense breasts. Future prospective studies are needed to evaluate the long-term prognostic impact of CEM screening.

Abbreviated Breast MRI as a Supplement to Mammography in Family Risk History of Breast Cancer within the Croatian National Breast Screening Program

OBJECTIVE

To evaluate the diagnostic performance of abbreviated breast MRI compared with mammography in women with a family history of breast cancer included in the Croatian National Breast Screening Program.

METHODS

178 women with a family history of breast cancer aged 50 to 69 underwent abbreviated breast MRI and mammography. Radiological findings for each method were categorized according to the BI-RADS classification. The gold standard for assessing the diagnostic accuracy of breast MRI and mammography, in terms of suspicious BI-RADS 4 and BI-RADS 5 findings, was the histopathological diagnosis. Performance measures, including cancer detection rates, specificity, sensitivity, and positive and negative predictive values, were calculated for both imaging methods.

RESULTS

Twelve new cases of breast cancer were detected, with seven (58.3%) identified only by abbreviated breast MRI, four (33.3%) detected by both mammography and breast MRI, and one (8.3%) diagnosed only by mammography. Diagnostic accuracy parameters for abbreviated breast MRI were 91.67% sensitivity, 94.58% specificity, 55.0% positive predictive value (PPV), and 99.37% negative predictive value (NPV), while for mammography, the corresponding values were 41.67%, 96.39%, 45.46%, and 95.81%, respectively.

CONCLUSIONS

Abbreviated breast MRI is a useful supplement to screening mammography in women with a family history of breast cancer. Considering the results of the conducted research, it is recommended to assess whether women with a family history of breast cancer have an increased risk and subsequently provide annual abbreviated breast MRI in addition to mammography for early detection of breast cancer.

A Nomogram Using Imaging Features to Predict Ipsilateral Breast Tumor Recurrence After Breast-Conserving Surgery for Ductal Carcinoma In Situ

OBJECTIVE

To develop a nomogram that integrates clinical-pathologic and imaging variables to predict ipsilateral breast tumor recurrence (IBTR) in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS).

MATERIALS AND METHODS

This retrospective study included consecutive women with DCIS who underwent BCS at two hospitals. Patients who underwent BCS between 2003 and 2016 in one hospital and between 2005 and 2013 in another were classified into development and validation cohorts, respectively. Twelve clinical-pathologic variables (age, family history, initial presentation, nuclear grade, necrosis, margin width, number of excisions, DCIS size, estrogen receptor, progesterone receptor, radiation therapy, and endocrine therapy) and six mammography and ultrasound variables (breast density, detection modality, mammography and ultrasound patterns, morphology and distribution of calcifications) were analyzed. A nomogram for predicting 10-year IBTR probabilities was constructed using the variables associated with IBTR identified from the Cox proportional hazard regression analysis in the development cohort. The performance of the developed nomogram was evaluated in the external validation cohort using a calibration plot and 10-year area under the receiver operating characteristic curve (AUROC) and compared with the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram.

RESULTS

The development cohort included 702 women (median age [interquartile range], 50 [44-56] years), of whom 30 (4%) women experienced IBTR. The validation cohort included 182 women (48 [43-54] years), 18 (10%) of whom developed IBTR. A nomogram was constructed using three clinical-pathologic variables (age, margin, and use of adjuvant radiation therapy) and two mammographic variables (breast density and calcification morphology). The nomogram was appropriately calibrated and demonstrated a comparable 10-year AUROC to the MSKCC nomogram (0.73 vs. 0.66, P = 0.534) in the validation cohort.

CONCLUSION

Our nomogram provided individualized risk estimates for women with DCIS treated with BCS, demonstrating a discriminative ability comparable to that of the MSKCC nomogram.

Commentary: Why is genetic testing underutilized worldwide? The case for hereditary breast cancer

It is thirty years since the BRCA1 and BRCA2 genes were discovered and genetic testing for BRCA1 and BRCA2 was introduced. Despite increasing awareness of the genetic basis of cancer and our evolving knowledge of effective means of prevention, screening, and treatment for hereditary breast and ovarian cancers, genetic testing is underutilized, and most mutation carriers remain unidentified. In this commentary, we explore possible reasons for why this might be so. Our focus is on factors that may influence or deter a patient from pursuing testing, rather than discussing the implications of receiving a positive test result. Issues of concern include an inadequate number of genetic counselors, restrictive (and conflicting) eligibility criteria for testing, the cost of the test, health insurance coverage, fear of future insurance discrimination, privacy issues, lack of familiarity with the testing process in primary care and gaps in both patient and provider knowledge about the impact and the value of testing. We discuss how these factors may lead to the underutilization of genetic testing in North America and throughout the world and discuss alternative models of genetic healthcare delivery. We have invited leaders in cancer genetic from around the world to tell us what they think are the barriers to testing in their host countries.

Surveillance Strategies After Primary Treatment for Patients with Invasive Lobular Carcinoma of the Breast: Method of Local Recurrence Detection After Breast-Conserving Surgery

BACKGROUND

Invasive lobular carcinoma (ILC) is the second most common subtype of breast cancer. Although mammography is known to have low sensitivity for ILC, there are no data to guide the optimal surveillance after treatment. We explored surveillance strategies after breast-conserving surgery (BCS) for ILC and determined the proportion of imaging-detected recurrences versus interval cancers.

METHODS

From an institutional database of 813 women, we retrospectively identified patients who underwent BCS for stage I-III ILC and subsequently had a recurrence. We categorized patients by surveillance strategy and determined the modality of recurrence detection. Interval cancer rates for local recurrences were compared across surveillance strategies using the Chi-square test. We evaluated overall survival with the log-rank test and a Cox proportional hazards model.

RESULTS

We included 58 patients with ILC who had a recurrence after BCS. Of these, 22 (37.9%) had local recurrence, 27 (46.6%) had distant recurrence, and 9 (15.5%) had both local and distant recurrence. Most patients underwent routine mammographic surveillance (65.2%), with 19.6% having supplemental breast magnetic resonance imaging (MRI) and 15.2% having no surveillance. The interval cancer rate was significantly higher in the mammographic surveillance group compared with the MRI surveillance group (61.9% vs. 16.7%; p < 0.001).

CONCLUSION

In this study of patients with recurrence after BCS for primary treatment of stage I-III ILC, we found that most local recurrences were not detected by surveillance mammography. These data support further investigation of supplemental imaging beyond mammography specifically for patients with ILC who undergo BCS.

Diagnostic Accuracy of Screening Contrast-enhanced Mammography for Women with Extremely Dense Breasts at Increased Risk of Breast Cancer

Background Mammogram interpretation is challenging in female patients with extremely dense breasts (Breast Imaging Reporting and Data System [BI-RADS] category D), who have a higher breast cancer risk. Contrast-enhanced mammography (CEM) has recently emerged as a potential alternative; however, data regarding CEM utility in this subpopulation are limited. Purpose To evaluate the diagnostic performance of CEM for breast cancer screening in female patients with extremely dense breasts. Materials and Methods This retrospective single-institution study included consecutive CEM examinations in asymptomatic female patients with extremely dense breasts performed from December 2012 to March 2022. From CEM examinations, low-energy (LE) images were the equivalent of a two-dimensional full-field digital mammogram. Recombined images highlighting areas of contrast enhancement were constructed using a postprocessing algorithm. The sensitivity and specificity of LE images and CEM images (ie, including both LE and recombined images) were calculated and compared using the McNemar test. Results This study included 1299 screening CEM examinations (609 female patients; mean age, 50 years ± 9 [SD]). Sixteen screen-detected cancers were diagnosed, and two interval cancers occured. Five cancers were depicted at LE imaging and an additional 11 cancers were depicted at CEM (incremental cancer detection rate, 8.7 cancers per 1000 examinations). CEM sensitivity was 88.9% (16 of 18; 95% CI: 65.3, 98.6), which was higher than the LE examination sensitivity of 27.8% (five of 18; 95% CI: 9.7, 53.5) (P = .003). However, there was decreased CEM specificity (88.9%; 1108 of 1246; 95% CI: 87.0, 90.6) compared with LE imaging (specificity, 96.2%; 1199 of 1246; 95% CI: 95.0, 97.2) (P < .001). Compared with specificity at baseline, CEM specificity at follow-up improved to 90.7% (705 of 777; 95% CI: 88.5, 92.7; P = .01). Conclusion Compared with LE imaging, CEM showed higher sensitivity but lower specificity in female patients with extremely dense breasts, although specificity improved at follow-up. © RSNA, 2024 See also the editorial by Lobbes in this issue.

Defining the Need for Services for Patients at High Risk of Breast Cancer at a Safety-Net Hospital: An Approach to Narrowing the Disparities Gap

BACKGROUND

The National Accreditation Program for Breast Cancer (NAPBC) standards were recently revised to promote breast cancer (BC) risk assessment and subsequent referral for high-risk services. This project sought to estimate the proportion of patients at high risk for BC in the authors' safety-net hospital system, gauge patient interest in high-risk services, and define resources for program development.

METHODS

Women presenting for breast imaging during 2 weeks in 2023 were surveyed. Thirty-five patients with a history or diagnosis of BC were excluded. The Tyrer-Cuzick (TC) model version 8 was used to calculate BC risk. High/intermediate risk was defined as a 10-year risk of 5% or more, a lifetime risk of 15% or more, or both. The criteria for genetic counseling and testing referral were based on National Comprehensive Cancer Network guidelines.

RESULTS

A total of 257 patients had a TC risk assessment showing 14.8% (n = 38) with a 10-year BC risk of 5% or more (consideration of endocrine therapy), 6.2% (n = 16) with a lifetime BC risk of 20% or more (qualifying for annual screening MRI), and 10.5% (n = 27) with a lifetime BC risk of 15% or more (consideration of high-risk screening). The criteria for genetic counseling/testing were met by 61 (23.7%) of the 257 patients. Overall, 31.5% (n = 81) qualified for high/intermediate-risk screening, risk reduction, and/or genetic assessment/testing, 92.8% of whom were interested in referrals for additional information and care.

CONCLUSIONS

In the authors' community, almost one third of patients undergoing breast imaging qualify for BC high-risk assessment and services. The majority of the patients expressed interest in pursuing such services. These data will be used in financial planning and resource allocation to develop a high-risk program at the authors' institution in line with NAPBC guidelines. They are hopeful that these efforts will improve oncologic outcomes and survival from BC in their community.

ESR Essentials: screening for breast cancer - general recommendations by EUSOBI

Breast cancer is the most frequently diagnosed cancer in women accounting for about 30% of all new cancer cases and the incidence is constantly increasing. Implementation of mammographic screening has contributed to a reduction in breast cancer mortality of at least 20% over the last 30 years. Screening programs usually include all women irrespective of their risk of developing breast cancer and with age being the only determining factor. This approach has some recognized limitations, including underdiagnosis, false positive cases, and overdiagnosis. Indeed, breast cancer remains a major cause of cancer-related deaths in women undergoing cancer screening. Supplemental imaging modalities, including digital breast tomosynthesis, ultrasound, breast MRI, and, more recently, contrast-enhanced mammography, are available and have already shown potential to further increase the diagnostic performances. Use of breast MRI is recommended in high-risk women and women with extremely dense breasts. Artificial intelligence has also shown promising results to support risk categorization and interval cancer reduction. The implementation of a risk-stratified approach instead of a "one-size-fits-all" approach may help to improve the benefit-to-harm ratio as well as the cost-effectiveness of breast cancer screening. KEY POINTS: Regular mammography should still be considered the mainstay of the breast cancer screening. High-risk women and women with extremely dense breast tissue should use MRI for supplemental screening or US if MRI is not available. Women need to participate actively in the decision to undergo personalized screening. KEY RECOMMENDATIONS: Mammography is an effective imaging tool to diagnose breast cancer in an early stage and to reduce breast cancer mortality (evidence level I). Until more evidence is available to move to a personalized approach, regular mammography should be considered the mainstay of the breast cancer screening. High-risk women should start screening earlier; first with yearly breast MRI which can be supplemented by yearly or biennial mammography starting at 35-40 years old (evidence level I). Breast MRI screening should be also offered to women with extremely dense breasts (evidence level I). If MRI is not available, ultrasound can be performed as an alternative, although the added value of supplemental ultrasound regarding cancer detection remains limited. Individual screening recommendations should be made through a shared decision-making process between women and physicians.

Diagnostic Value of Artificial Intelligence in Minimal Breast Lesions Based on Real-Time Dynamic Ultrasound Imaging

Purpose

: To explore the diagnostic value of artificial intelligence (AI)-based on real-time dynamic ultrasound imaging system for minimal breast lesions.

Patients and Methods

Minimal breast lesions with a maximum diameter of ≤10mm were selected in this prospective study. The ultrasound equipment and AI system were activated Simultaneously. The ultrasound imaging video is connected to the server of AI system to achieve simultaneous output of AI and ultrasound scanning. Dynamic observation of breast lesions was conducted via ultrasound. And these lesions were evaluated and graded according to the Breast Imaging Reporting and Data System (BI-RADS) classification system through deep learning (DL) algorithms in AI. Surgical pathology was taken as the gold standard, and ROC curves were drawn to determine the area under the curve (AUC) and the optimal threshold values of BI-RADS. The diagnostic efficacy was compared with the use of a BI-RADS category >3 as the threshold for clinically intervening in diagnosing minimal breast cancers.

Results

291 minimal breast lesions were enrolled in the study, of which 228 were benign (78.35%) and 63 were malignant (21.65%). The AUC of the ROC curve was 0.833, with the best threshold value >4A. When using >BI-RADS 3 and >BI-RADS 4A as threshold values, the sensitivity and negative predictive value for minimal breast cancers were higher for >BI-RADS 3 than >BI-RADS 4A (100% vs 65.08%, 100% vs 89.91%, P values <0.001). However, the corresponding specificity, positive predictive value, and accuracy were lower than those for >BI-RADS 4A (42.11% vs 85.96%, 32.31% vs 56.16%, and 54.64% vs 81.44%, P values <0.001).

Conclusion

The AI-based real-time dynamic ultrasound imaging system shows good capacity in diagnosing minimal breast lesions, which is helpful for early diagnosis and treatment of breast cancer, and improves the prognosis of patients. However, it still results in some missed diagnoses and misdiagnoses of minimal breast cancers.

Strategies for Identifying and Recruiting Women at High Risk for Breast Cancer for Research Outside of Clinical Settings: Observational Study

BACKGROUND

Research is needed to understand and address barriers to risk management for women at high (≥20% lifetime) risk for breast cancer, but recruiting this population for research studies is challenging.

OBJECTIVE

This paper compares a variety of recruitment strategies used for a cross-sectional, observational study of high-risk women.

METHODS

Eligible participants were assigned female at birth, aged 25-85 years, English-speaking, living in the United States, and at high risk for breast cancer as defined by the American College of Radiology. Individuals were excluded if they had a personal history of breast cancer, prior bilateral mastectomy, medical contraindications for magnetic resonance imaging, or were not up-to-date on screening mammography per American College of Radiology guidelines. Participants were recruited from August 2020 to January 2021 using the following mechanisms: targeted Facebook advertisements, Twitter posts, ResearchMatch (a web-based research recruitment database), community partner promotions, paper flyers, and community outreach events. Interested individuals were directed to a secure website with eligibility screening questions. Participants self-reported method of recruitment during the eligibility screening. For each recruitment strategy, we calculated the rate of eligible respondents and completed surveys, costs per eligible participant, and participant demographics.

RESULTS

We received 1566 unique responses to the eligibility screener. Participants most often reported recruitment via Facebook advertisements (724/1566, 46%) and ResearchMatch (646/1566, 41%). Community partner promotions resulted in the highest proportion of eligible respondents (24/46, 52%), while ResearchMatch had the lowest proportion of eligible respondents (73/646, 11%). Word of mouth was the most cost-effective recruitment strategy (US $4.66 per completed survey response) and paper flyers were the least cost-effective (US $1448.13 per completed survey response). The demographic characteristics of eligible respondents varied by recruitment strategy: Twitter posts and community outreach events resulted in the highest proportion of Hispanic or Latina women (1/4, 25% and 2/6, 33%, respectively), and community partner promotions resulted in the highest proportion of non-Hispanic Black women (4/24, 17%).

CONCLUSIONS

Although recruitment strategies varied in their yield of study participants, results overall support the feasibility of identifying and recruiting women at high risk for breast cancer outside of clinical settings. Researchers must balance the associated costs and participant yield of various recruitment strategies in planning future studies focused on high-risk women.

Optimizing the Patient Experience in Breast Imaging Facilities: AJR Expert Panel Narrative Review

Breast imaging studies are complex examinations for patients and providers. Breast imaging providers and organizations invest significant resources in educating patients and referring physicians to address variability in changing breast cancer screening recommendations, cultural biases, and socioeconomic barriers for patients. The breast imaging examination frequently involves multiple imaging modalities, including interventional procedures, thus requiring multiple room types. Practices need to consider the variables that affect workflow efficiency throughout the process of examination scheduling, performance, interpretation, and results delivery, as well as options in facilities design for creating inviting yet functional environments for patients. Breast imaging appointments provide an opportunity to capture individual breast cancer risk and to engage patients in health education and breast screening awareness. This AJR Expert Panel Narrative Review discusses ways in which breast imaging facilities can optimize a patient's experience throughout the complex process of a breast imaging examination, based on the authors' observations and opinions informed by private and academic breast imaging experience.