Q. My patient does NOT have dense breasts but she still wants additional breast screening studies.
A. Assure the patient that she is not at increased risk for breast cancer and that annual screening mammography is the current best screening method for breast cancer for women of all breast densities.
Other supplemental screening studies exist (MRI, ultrasound, tomosynthesis) but will likely not be covered by insurance for patients that do not have dense breasts.
Q. My patient has dense breasts. Should she be screened with something different than mammography?
A. Explain that at this point, there is no other method recommended to replace mammography. There are certain signs of cancer (for example, calcifications) that are best seen on a mammogram. Other “screening” options are not meant to replace mammography. These studies are done as a supplement.
Q. What role does tomosynthesis play in breast cancer screening?
A. Tomosynthesis is an emerging imaging modality that has shown promise in early clinical trials. Its role in breast cancer screening is currently being evaluated. It improves specificity by decreasing recall rates. It may improve sensitivity, yet probably more for
heterogenous than extremely dense tissue.
Q. My patient has dense breasts and a normal mammogram. How does supplemental Ultrasound compare to supplemental MRI screening?
A. The American College of Radiology Imaging Network 6666 Study was the largest trial of screening ultrasound in which mammography and ultrasound were performed and read independently.
A subset of patients also had MRI. All patients were at least intermediate to high risk. More than half had a history of breast cancer (54%); others had a high risk profile using the Gail model (24%) or a lifetime risk >25% (19%). Mammography identified 7.6 cancers per 1000 patients. Adding Ultrasound found 4.3 more cancers per 1000 patients. MRI however found 14.7 more cancers per 1000 patients. Cancers seen only on ultrasound were evenly distributed across breast density categories, which included 0-20%, 20-40%, 40-60%, 60-80%, and 80-100%, in at least one quadrant on mammography.
5% patients screened by Ultrasound were recommended for biopsy with a low PPV of 7.4% compared to a PPV of 38 % for mammography with 2% sent for biopsy. By comparison, 19% of participants biopsied because of a finding solely identified on MRI were found to have cancer.
12.2% of all patients screened by ultrasound were classified as BIRADS 3 requiring serial follow-up studies versus 6.7% for mammography. 1.6% of those patients classified as BIRADS 3 on Ultrasound were diagnosed with cancer, however 60% of those cancers were found on mammography as well.
The number of screens needed to detect 1 cancer was 127 for mammography; 234 for supplemental ultrasound, and 68 for supplemental MRI after negative mammography plus ultrasound screening results.
An April 2014 Committee Opinion from The American College of Obstetricians and Gynecologists does not recommend routine use of alternative or adjunctive tests to screening mammography in women with dense breasts who are asymptomatic and have no additional risk factors.
For more information about the breast imaging program
at Atlantic Medical Imaging, please visit: women.myamihealth.com
