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• W4207079968 abstract "I am troubled by the new ACR Appropriateness Criteria (AC) for supplemental breast cancer screening based on breast density [1Weinstein S.P. Slanetz P.J. et al.Expert Panel on Breast ImagingACR Appropriateness Criteria® supplemental breast cancer screening based on breast density.J Am Coll Radiol. 2021; 18: S456-S473Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar]. As an advocate for supplemental screening beyond tomosynthesis, I am disappointed that tomosynthesis is the only supplemental screening examination considered “usually appropriate” for individuals with dense breast tissue at average to intermediate lifetime risk for breast cancer. Too many individuals in this category present with advanced breast cancer that went undetected by tomosynthesis. Despite having some benefits, tomosynthesis infrequently unmasks cancers obscured by dense breast tissue, especially if breast tissue is extremely dense [2Berg W.A. Rafferty E.A. Friedewald S.M. Hruska C.B. Rahbar H. Screening algorithms in dense breasts: AJR expert panel narrative review.AJR Am J Roentgenol. 2021; 216: 275-294Crossref PubMed Scopus (28) Google Scholar,3Vourtsis A. Berg W.A. Breast density implications and supplemental screening.Eur Radiol. 2019; 29: 1762-1777Crossref PubMed Scopus (88) Google Scholar]. Per the ACR AC, the incremental cancer detection rate—the number of cancers beyond 2-D mammography per 1,000 individuals screened—is sufficiently low for tomosynthesis that statistical significance for superiority to 2-D mammography was not met in several studies [1Weinstein S.P. Slanetz P.J. et al.Expert Panel on Breast ImagingACR Appropriateness Criteria® supplemental breast cancer screening based on breast density.J Am Coll Radiol. 2021; 18: S456-S473Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar]. The ACR AC report an incremental cancer detection rate of 1.2 to 3.0 for tomosynthesis compared with up to 15.5 for MRI [1Weinstein S.P. Slanetz P.J. et al.Expert Panel on Breast ImagingACR Appropriateness Criteria® supplemental breast cancer screening based on breast density.J Am Coll Radiol. 2021; 18: S456-S473Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar]. Individuals with dense breast tissue at average to intermediate risk may therefore be underscreened by a tomosynthesis-predominant approach. I am deeply concerned by the following issues:1.These ACR recommendations provide justification for insurers to deny coverage for nontomosynthesis supplemental screening despite research demonstrating benefit for patients. Reduced access to supplemental screening beyond tomosynthesis will allow some breast cancers to needlessly go undetected until advanced stages, causing morbidity from aggressive therapies and preventable deaths.2.Failure to endorse supplemental screening that is not affected by dense breast tissue as “usually appropriate” will cause individuals with dense breasts to fare worse on screening than those with nondense breasts. Inequalities in breast cancer screening will continue on the basis of breast density. This is highly concerning given that breast density varies by age and race.3.If insurers limit coverage on the basis of ACR recommendations, supplemental screening beyond tomosynthesis may be available only on a self-pay basis, facilitating socioeconomic disparities in supplemental screening access.4.In most US states, individuals receive dense breast tissue notification letters stating a potential need for supplemental screening. Confusion and/or false reassurance may result from the ACR’s rating tomosynthesis, the very examination that frequently triggers these letters, as the most appropriate examination for supplemental screening. Many individuals with dense breast tissue want access to nontomosynthesis supplemental screening to find those cancers that tomosynthesis, performed for primary screening, cannot. I assert that it is “usually appropriate” to provide robust supplemental screening, including contrast-enhanced mammography, breast MRI, and/or molecular breast imaging, to any individual with dense breast tissue who, on the basis of informed decision making, desires additional screening with these modalities. Unfortunately, these ACR recommendations further the status quo and potentially worsen access to breast cancer screening beyond tomosynthesis for the majority of individuals with dense breast tissue. Legislation mandating insurance coverage of nontomosynthesis supplemental screening, such as existing laws in several US states mandating coverage for screening breast ultrasound, may be necessary to overcome the ACR AC’s imprudent assertion that tomosynthesis is best for dense breast tissue supplemental screening. ResponseJournal of the American College of RadiologyVol. 19Issue 5PreviewThank you for your comments regarding the recently published ACR Appropriateness Criteria® (AC) Guideline for Supplemental Breast Cancer Screening Based on Breast Density [1]. The goal of the ACR AC Committee is to provide evidence-based guidance to health care providers in the judicious use of imaging while caring for patients. The AC panels are composed of a broad range of experts in both radiology and interfacing clinical specialties. The supporting evidence for every guideline is gathered via a comprehensive and rigorous literature search that identifies relevant peer-reviewed literature. 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• W4207079968 date "2022-05-01" @default.
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• W4207079968 title "Rethinking the ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density" @default.
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