The end of one-size-fits-all screening mammography may be near

The screening mammo war may be drawing to a close to be replaced by a model of personalized screening based on a woman’s genetic, phenotypic and clinical profiles—an approach that will require much closer collaboration between breast imagers and clinicians, according to a review and accompanying editorial published in the April issue of The American Journal of Medicine.

Jennifer S. Drukteinis, MD, from H. Lee Moffitt Cancer Center in Tampa, Fla., and colleagues reviewed the utility and drawbacks of screening mammography and presented the need for improved breast cancer screening. “We propose that optimal patient care will ultimately require a new paradigm, with adoption of patient-specific screening strategies tailored to risk assessment based on family history, age, genetic profiles, and breast density,” the researchers wrote.

Drukteinis et al outlined potential roles for multiple emerging technologies. These include:

• Low-dose mammography, such as spectral imaging or photon counting, could halve the 3.7 mGy average mean glandular dose from digital mammography, while providing acceptable image quality. The FDA has approved a low-dose photon-counting mammography system.
• Contrast-enhanced mammography provides the capability to image blood flow and delivers sensitivity for tumor detection from 78 to 92 percent. The FDA has approved contrast-enhanced digital mammography as an adjunct to standard mammography.
• Digital breast tomosynthesis may address the challenges posed by overlapping breast tissue, which could curb recall rates and false negatives. However, it ups radiation exposure to 1.5-4 mGy per acquisition. It also may be less sensitive for microcalcifications. The FDA approved tomosynthesis as an adjunct to conventional mammography.
• Automated breast density assessments might address the marked and subjective interobserver variability among radiologists in determining breast density. Several systems are commercially available. Meanwhile, five states have passed breast density notification legislation, with similar legislation pending in at least 11 more states and a bill introduced in the U.S. House of Representatives.
• Automated whole-breast ultrasound may standardize screening ultrasound, which is compromised by a high level of interoperator variability.
• High-risk screening and MRI have been demonstrated to be superior to mammography and ultrasound in the detection of invasive breast cancer among high-risk groups, and MRI is recommended as an adjunct to screening mammography for first-degree relatives of BRCA carriers and those with a lifetime risk that exceeds 20-25 percent of an average woman.
• Molecular imaging, positron emission mammography and breast specific gamma imaging, offer high positive predictive value and low negative predictive values. However, with a radiation dose on par with 20 to 30 mammograms, these modalities are limited to staging rather than screening.

Given the evolving imaging options and increasing patient engagement, Drukteinis et al advocated a personalized breast cancer screening strategy that leverages risk stratification tools, breast density and patient preferences as well as the specific advantages of various modalities.

The researchers also noted the staying power of screening mammography and predicted that no single new technology could replace the gold standard. “Furthermore, given the heterogeneity of the human population, a 'perfect'” imaging technology for breast cancer screening will likely never be found,” added Drukteinis et al.

“The seemingly endless and often overwrought debate about the utility of screening mammography may finally be drawing to a close,” wrote Robert G. Stern, MD, from the department of medical imaging at the University of Arizona College of Medicine in Tucson, in the editorial.

He outlined implications for clinicians, noting they could not merely order a screening mammogram based on an EHR pop-up. Instead, providers need to understand risk stratification, new modalities and clinical context, which relates to the key point for radiologists.

“There will need to be a much closer working relationship between breast imagers and clinicians so that all women receive the optimal breast cancer screening that they individually require based on their genetic, phenotypic, and clinical profiles.”

For more about emerging breast imaging modalities, please read "Move over Mammo," and "Breast Ultrasound Screening Marches into Practice," in Health Imaging.