Europe: Ecancer.org Editorial Board
Our congratulations to Cheryl Cruwys, DB-i’s European Education Coordinator, on her appointment to the ecancer.org editorial board. ecancer is charity providing universal access to high quality educational content to help the global oncology community raise standards of care. Cheryl’s focus and mission on educating about the implications of dense tissue will make hers a valuable voice on the Editorial Board.
Research Launch:
There was strong interest from the radiological press in the research launch news release sent out earlier this week. It was picked up by AuntMinnie, Radiology Business and DOTMed. DOTMed included the acknowledgement of our DB-i Supporters and we thank those organizations that help keep our Education Coalition viable through unrestricted educational grants and donations. The full news release is now posted on the DB-i website, in the event you want to share it with any of your contacts.
Patient Brochures:
In other updates, we’ve given our Patient Brochure a facelift. You can access the brochure, available in English and Spanish, through either the “For Patients” or “For Health Professionals” tab on the home page. The Spanish version can also be accessed through the Español tab located in the website’s top navigation bar. Did you know the Español tab contains a full suite of Spanish-language patient tools?
Expanded FAQs for Patients and Providers
We’ve recently expanded our FAQs and added 3 new questions:
Hellenic Breast Imaging Society Meeting 2019
DBI’s Chief Scientific Advisor, Dr. Wendie Berg, and Dr. Athina Vourtsis, DBI’s European Liaison, presented a talk about the implications of breast density and the Eu.DenseBreast-info.org educational initiative at the Hellenic Breast Imaging Society meeting on May 3 – 4 in Athens Greece. Dr. Vourtsis is Founding President of the Society; the meeting’s topic was The Present and the Future in Breast Imaging.
Legislation News: Georgia Signs On!
Georgia joins the ranks of those states that have breast density inform laws. The state became the 38th to require health care facilities conducting mammograms to provide some form of notification about breast density to patients and referring health care providers. Bill HB62 —also known as Margie’s Law—was named for Margie Singleton who led the advocacy effort on this issue after she was diagnosed with breast cancer that was missed due to dense breast tissue.
You can read our full press release here.
Check out our interactive map for the full list of states with breast density inform laws and our National Reporting Standard page for the latest on the FDA’s Mammography Quality Standards Act (MQSA).
The Case for Screening at 40
Do you have questions about when to kick off your breast cancer screening? Our updated Patient and Provider FAQ says 40 is the age to start. Breast cancer is the number one cause of death in women aged 35 – 54 years. Earlier screening gives patients and providers an edge on finding cancer in its early stages. Younger women are more likely to have dense breast tissue which means cancers can hide like a snowflake in a snowstorm.
Refer to our new FAQ for more details on the benefits of mammography screening at 40, including more detail on insurance coverage issues, demystifying “false positives” and screening for women with dense breasts.
Facebook 10K and Counting
It’s official! DenseBreast-info.org now has over 10,000 Facebook followers. In addition to our website and educational videos, we consider our social networks and audiences to be a crucial part of our community. Thank you for helping us reach this milestone and continue to share, comment and like our posts to keep the conversation moving forward.
Website Updates on Screening Technologies
We are busily updating the Screening Technologies section of the website, with the expert input from our Medical Advisory Board members. Check out the recently completed Mammography/3D Mammography (Tomosynthesis) and Breast Ultrasound sections and stay tuned for further updates.
Proposed MQSA Amendment:
Dr. Wendie Berg provided her perspective on the FDA’s proposed MQSA amendment during an interview with Imaging Technology News (ITN) at the SBI conference last week. See the full interview for comments focused on the proposed breast density inform language and how it could be strengthened, as well as its potential impact on the 37 states with existing inform laws.
Europe Expansion:
Exciting news on the European front! DB-i welcomes Professor Dr. Erkin Aribal as the Education Ambassador for Turkey and the European Screening Guidelines Map has now been expanded to include Turkey and Norway.
An abstract presented at the American Roentgen Ray Society meeting on May 2, 2017 in New Orleans by Dr. Stamatia Destounis.
Researchers at Elizabeth Wende Breast Care in Rochester, New York, conducted a two-and-a-half year study of 7,146 women screened with digital breast tomosynthesis (aka DBT, 3D mammography) followed by ultrasound (sonogram). Led by Dr. Stamatia Destounis, the study was performed in patients with heterogeneously or extremely dense breasts. This retrospective review compared cancer detection, type of cancer diagnosed, tumor size and lymph node status in cancers detected by technologist performed ultrasound and DBT in women with dense breasts. There were 39 cancers (30 invasive) found, though not at the same rate.
The additional screening tests found a total of 39 breast cancers:
The four DBT-only detected cancers were seen as calcifications, which demonstrates a limitation of ultrasound. Ultrasound detected all but one invasive carcinoma in the group. Minor differences in lesion size were observed, with smaller average size in the ultrasound only group. Ultrasound overall performed better at identifying cancers in this group.
ASTOUND-2 [1] is a large, prospective multicentre trial in Italy that directly compares the incremental cancer detection and “false positive” (false alarm) recall rates for ultrasound (sonogram) and tomosynthesis (a form of 3D mammography) in women with dense breasts after a negative standard (2D) mammogram. In 5,300 women with dense breasts, the additional screening tests found a total of 29 breast cancers missed by 2D mammography:
Based on the number of women screened, tomosynthesis detected an additional 2.8 breast cancers per 1,000 women screened. Ultrasound detected significantly more, at 4.9 breast cancers per 1,000 women screened and an additional 2.6 breast cancers per 1,000 women even after tomosynthesis (p=0.015).
While additional screening with ultrasound detects more breast cancers than 3-D mammography, false positive rates are higher for ultrasound than for 3-D mammography in most studies, resulting in a greater number of women being called back for additional testing. In the ASTOUND study, the incremental false-positive recall rate was significantly higher for ultrasound (1.0%) compared to tomosynthesis (0.30%) (p < 0.001).
DO I NEED A MAMMOGRAM BEFORE I TURN 45? YES.
WHAT ABOUT FALSE ALARMS (KNOWN AS “FALSE POSITIVES”)?
WHAT ABOUT SCREENING IN DENSE BREASTS?
IS IT COVERED?
Insurance coverage for additional screening tests, such as ultrasound or MRI, varies by state and by insurance company. Women should check with their insurance carriers to determine how additional tests will be covered. In women at high risk for breast cancer, most insurers will cover screening MRI (regardless of density) though a deductible/co-pay will typically apply and pre-authorization may be needed.
The American College of Radiology (ACR [1]) recommends all women, and especially black women and those of Ashkenazi Jewish descent, should undergo risk assessment by age 30 so that women at higher risk can be identified and begin earlier and more aggressive screening for breast cancer. In a separate recent analysis [2] from Harvard, black, Hispanic, and Asian women have peak incidence of breast cancer in their 40s and should begin screening at least by age 40.
The ACR reaffirmed recommendations for annual MRI in the following groups, with slight refinements:
The ACR newly endorses annual screening MRI in addition to annual mammography or tomosynthesis for women in the following situation (provided the patient has not had bilateral mastectomy):
The ACR suggests annual MRI be considered in addition to annual mammography or tomosynthesis in women with a history of LCIS or prior atypia (ADH, ALH, atypical papilloma), especially if other risk factors are present, though further study of the benefit of MRI is needed.
In women who meet guidelines for MRI screening but are unable to tolerate it and who have dense breasts, the ACR suggests ultrasound be considered in addition to annual mammography. Tomosynthesisis expected to reduce the benefit of supplemental screening ultrasound, depicting about half of the cancers that would have been seen only on ultrasound after 2D mammography, though further study is warranted. If MRI is performed, there is no benefit to screening ultrasound.
A trial evaluating screening ultrasound after tomosynthesis (3D mammography) is ongoing at the University of Pittsburgh School of Medicine/UPMC. The study is funded by the National Cancer Institute and the Pennsylvania Breast Cancer Coalition and will recruit 6,200 women. Participants will receive screening ultrasound each year for three years as part of the study provided 3D mammography is included as part of their usual breast screening. Results are expected in late 2021.
ASTOUND is the first published prospective multicenter trial to directly compare cancer detection and “false positive” (false alarm) rates of ultrasound (sonogram) and tomosynthesis (a form of 3D mammography) in women with dense breasts after a standard (2D) mammogram. In over 3,000 women with dense breasts in Italy, it was found that adding tomosynthesis or physician-performed ultrasound detected an additional 24 cancers (23 invasive), though not at the same rate.
The additional screening tests found a total of 24 breast cancers missed by 2D mammography:
Based on the number of women screened, tomosynthesis detected an additional four breast cancers per 1,000 women screened and ultrasound detected significantly more, an additional seven breast cancers per 1,000 women screened.
The study publication and accompanying editorial by Dr. Wendie A. Berg were featured in the Journal of Clinical Oncology , March 9, 2016. Dr. Berg addresses how the acceptably low and comparable false-positive rates found in the ASTOUND study (107 false-positive recalls, 53 for 3-D mammograms, 65 for ultrasound, with a total of 38 false positive biopsies, 22 for 3-D mammograms and 24 for ultrasound) have implications for new screening protocols.
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