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• W3086824863 abstract "HomeRadiologyVol. 297, No. 3 PreviousNext Reviews and CommentaryFree AccessEditorialDigital Breast Tomosynthesis Screening: Better But Still Not Good Enough for All WomenIoannis Sechopoulos , Alexandra AthanasiouIoannis Sechopoulos , Alexandra AthanasiouAuthor AffiliationsFrom the Department of Medical Imaging, Radboud University Medical Center, PO Box 9101 (766), 6500 HB Nijmegen, the Netherlands (I.S.); Dutch Expert Centre for Screening (LRCB), Nijmegen, the Netherlands (I.S.); and Breast Imaging Section, Department of Radiology, MITERA Hospital, Athens, Greece (A.A.).Address correspondence to I.S. (e-mail: [email protected]).Ioannis Sechopoulos Alexandra AthanasiouPublished Online:Sep 15 2020https://doi.org/10.1148/radiol.2020203494MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Moshina et al in this issue.Dr Sechopoulos is an associate professor and leads the Advanced X-ray Tomographic Imaging Laboratory in the Department of Medical Imaging at the Radboud University Medical Center and is also appointed at the Dutch Expert Centre for Screening (LRCB). His research interests focus on various aspects of x-ray imaging, especially for breast imaging. He is a fellow of the American Association of Physicists in Medicine and is principal investigator of various European, Dutch, and National Institutes of Health grants.Download as PowerPointOpen in Image Viewer Dr Athanasiou has been the director of the Breast Imaging Section and the clinical director of the Breast Unit of the MITERA Hospital in Athens, Greece, since 2015. Her research interests focus on high-risk screening and advanced modalities for breast imaging. She holds a master’s degree in biomedical engineering and has been principal or co-investigator of various European grants. She is a member of the scientific committee of the European Society of Breast Imaging, the European Society of Radiology e-Learning Subcommittee, and part of the Faculty of the European School Of Radiology.Download as PowerPointOpen in Image Viewer Denser breasts have a higher percentage of fibroglandular tissue than adipose tissue. This presents two problems for digital mammography (DM)-based breast cancer screening: a higher risk of breast cancer for dense breasts than for nondense breasts (1) and a lower effectiveness of DM in the detection of cancer (2). The latter is due to the fact that solid lesions in DM are distinguishable, for the most part, only when they are at least partially surrounded by fatty tissue. This is because there is no substantial difference in contrast between a breast tumor and normal fibroglandular tissue; in other words, DM is a morphologic imaging modality. The two-dimensional nature of DM increases the chances of superimposed fibroglandular tissue surrounding a lesion of interest, rendering the lesion invisible. Also, the projections of vertically separated normal tissues may mimic the features of a lesion, causing a false-positive recall. As a result, the introduction of digital breast tomosynthesis (DBT) almost a decade ago, a pseudo-tomographic imaging modality, held the promise of improved screening performance. The ability of DBT to partially depict the true tissue distribution in the third dimension reduces the chances of false-negative and false-positive results caused by tissue superposition, and this improves screening outcomes.However, since DBT is a morphologic imaging modality, is there a limit to the positive impact of DBT on screening performance? How does DBT perform in the densest breasts compared with DM? Conversely, is there any benefit to using DBT instead of DM in fatty breasts? Finally, how does breast density impact DBT screening performance overall, and how does this compare with its impact on DM screening? In this issue of Radiology, Moshina et al (3) performed a secondary analysis of the results of the To-Be randomized control trial on breast cancer screening with DBT to address these questions.The To-Be trial compared screening with DBT combined with synthetic mammography (SM) (a two-dimensional image similar to a mammogram composed only from the DBT data) (hereafter, DBT+SM) with screening with DM only in more than 28 000 women invited to screening as part of the Norwegian breast cancer population screening program. Overall, and in stark contrast to other DBT screening trials, the investigators found a similar screening-detected breast cancer rate between the DBT+SM and DM arms (4). Moshina and colleagues compared the recall, false-positive, biopsy, and screening-detected breast cancer rates, along with the histopathologic characteristics of the cancers found in each arm, discriminated by breast density category. The authors used a commercial automated image analysis method to measure breast density rather than the subjective grading of the interpreting radiologists. Although the radiologist’s density rating is probably still the most common method to assess breast density, the use of such automated algorithms is becoming commonplace. Although the accuracy of these algorithms remains unverified (compared with independent ground truth of the dense tissue in the same field of view), these algorithms are considered precise and correlate with radiologist assessment (5).When compared with DM, the use of DBT+SM had a lower recall rate in the To-Be trial, both overall and for the two lower breast density categories; however, the recalling of higher-density breasts showed no difference. Many other studies have shown the benefits of DBT in reducing false-positive findings, even in fatty breasts, with reduced risk of tissue superposition. But does the advantage of DBT in helping resolve false-positive concerns disappear for very dense breasts, resulting in equivalent recall rates as with DM? The highest-density breasts, those with a Volpara Density Grade (VDG) of 4, did not have a lower recall rate with DBT+SM compared with DM (3% vs 4%, P = .26). Breasts with a VDG of 3 had similar recall rates between DBT+SM and DM. Similarly, Østerås et al found a smaller decrease in recalls with DBT+DM for dense breasts, and even a slight increase in recall for the densest breasts (6).These two reports contradict various other screening trials and reports, but most of those studies come from the United States. In European screening programs, the recall rates are much lower than those in the United States. The overall recall rates in the To-Be trial were 4% for DM and 3% for DBT+SM compared with 10% or higher recall rates for DM in the United States. In very low recall scenarios, like those in Sweden and the Netherlands, with an overall rate of approximately 2.5% for DM, introduction of DBT would result in more recalls (7). Another deviation from previous reports (2,6,8) is that in the To-Be trial the recall rate for DM did not show a significant change for denser breasts, in essence being constant for all but the least-dense breasts. This is surprising and may help explain why the differences in recall rate between DM and DBT diminished with denser breasts.For the denser breasts (VDG 2–4), the increased relative risks of screen-detected cancers in the DBT+SM arm were significant. Other studies have also reported increases in screen-detected cancer rates for denser breasts (2,6). Hence, this study aligns with previous findings with respect to cancer detection.Thus, it seems that in low DM recall rate (approximately 4%) scenarios, while DBT can further avoid unnecessary recalls in low-density breasts, this is not the case for very dense breasts. DBT also results in a higher cancer detection rate for denser breasts, but this increase is similar to that found in DM screening. Unfortunately, these increases in cancer detection rates with either DM or DBT screening (approximately 40% higher) are smaller than the expected increases in cancers present in these subgroups (more than 100% higher) (2). This may help explain the current lack of evidence on reduction of interval cancers with DBT screening.Thus, as mentioned by Moshina et al, some form of supplemental screening in the women with denser breasts seems necessary, even after the introduction of DBT. The prime candidate for such supplemental screening is dynamic contrast-enhanced (DCE) breast MRI, which can provide much needed functional information with very promising results (9). The functional information resulting from the use of contrast enhancement results in a substantial increase in cancer detection, even in the densest breasts (which does not affect DCE MRI). However, contrast-enhanced spectral mammography (and contrast-enhanced DBT) are much more affordable imaging platforms than DCE MRI, despite similar functional information. Thus, these modalities could have the same (10) or a larger impact on breast screening to solve the shortcomings of morphologic-only imaging that not even DBT can escape.Disclosures of Conflicts of Interest: I.S. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: institution received grants from Siemens Healthcare, Screenpoint Medical, Volpara Solutions, Sectra Benelux, and Canon Medical Systems; gave lectures for Siemens Healthcare and Hologic. Other relationships: disclosed no relevant relationships. A.A. disclosed no relevant relationships.References1. Chiu SYH, Duffy S, Yen AMF, Tabár L, Smith RA, Chen HH. Effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-year follow-up of a Swedish mammographic screening. Cancer Epidemiol Biomarkers Prev 2010;19(5):1219–1228. Crossref, Medline, Google Scholar2. Wanders JOP, Holland K, Veldhuis WB, et al. Volumetric breast density affects performance of digital screening mammography. Breast Cancer Res Treat 2017;162(1):95–103. Crossref, Medline, Google Scholar3. Moshina N, Aase HS, Skyrud Danielsen A, et al. Comparing screening outcomes for digital breast tomosynthesis and digital mammography by automated breast density in a randomized controlled trial: results from the To-Be trial. Radiology 2020;297:522–531. Link, Google Scholar4. Hofvind S, Holen ÅS, Aase HS, et al. Two-view digital breast tomosynthesis versus digital mammography in a population-based breast cancer screening programme (To-Be): a randomised, controlled trial. Lancet Oncol 2019;20(6):795–805. Crossref, Medline, Google Scholar5. van der Waal D, den Heeten GJ, Pijnappel RM, et al. Comparing Visually Assessed BI-RADS Breast Density and Automated Volumetric Breast Density Software: A Cross-Sectional Study in a Breast Cancer Screening Setting. PLoS One 2015;10(9):e0136667. Crossref, Medline, Google Scholar6. Østerås BH, Martinsen ACT, Gullien R, Skaane P. Digital Mammography versus Breast Tomosynthesis: Impact of Breast Density on Diagnostic Performance in Population-based Screening. Radiology 2019;293(1):60–68. Link, Google Scholar7. Zackrisson S, Lång K, Rosso A, et al. One-view breast tomosynthesis versus two-view mammography in the Malmö Breast Tomosynthesis Screening Trial (MBTST): a prospective, population-based, diagnostic accuracy study. Lancet Oncol 2018;19(11):1493–1503. Crossref, Medline, Google Scholar8. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013;14(7):583–589. Crossref, Medline, Google Scholar9. Bakker MF, de Lange SV, Pijnappel RM, et al. Supplemental MRI Screening for Women with Extremely Dense Breast Tissue. N Engl J Med 2019;381(22):2091–2102. Crossref, Medline, Google Scholar10. Fallenberg EM, Schmitzberger FF, Amer H, et al. Contrast-enhanced spectral mammography vs. mammography and MRI: clinical performance in a multi-reader evaluation. Eur Radiol 2017;27(7):2752–2764. Crossref, Medline, Google ScholarArticle HistoryReceived: Aug 20 2020Revision requested: Aug 24 2020Revision received: Aug 25 2020Accepted: Aug 26 2020Published online: Sept 15 2020Published in print: Dec 2020 FiguresReferencesRelatedDetailsAccompanying This ArticleComparing Screening Outcomes for Digital Breast Tomosynthesis and Digital Mammography by Automated Breast Density in a Randomized Controlled Trial: Results from the To-Be TrialSep 15 2020RadiologyRecommended Articles Clinical Performance of Synthesized Two-dimensional Mammography Combined with Tomosynthesis in a Large Screening PopulationRadiology2017Volume: 283Issue: 1pp. 70-76Tomosynthesis Is Taking Small Steps to Become the Standard for Breast Cancer ScreeningRadiology2021Volume: 299Issue: 3pp. 568-570Lessons Learned from the Randomized Controlled TOmosynthesis plus SYnthesized MAmmography (TOSYMA) TrialRadiology2022Volume: 306Issue: 2Breast Density and TomosynthesisRadiology2021Volume: 301Issue: 3pp. 569-570The Impact of Acquisition Dose on Quantitative Breast Density Estimation with Digital Mammography: Results from ACRIN PA 4006Radiology2016Volume: 280Issue: 3pp. 693-700See More RSNA Education Exhibits Let’s Talk about Next-Generation Breast Cancer Screening Programs: How Should We Do? What Should We Use?Digital Posters2020Hiding in Plain Sight: Cancers in Dense BreastsDigital Posters2022Breast Density Included in the Modern Rules of Mammographic ScreeningDigital Posters2019 RSNA Case Collection Left breast hamartomaRSNA Case Collection2020Invasive Lobular CarcinomaRSNA Case Collection2021Invasive ductal carcinoma as developing asymmetryRSNA Case Collection2021 Vol. 297, No. 3 Metrics Altmetric Score PDF download" @default.
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