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Screening

Flowchart Update; CEM Study

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Who Needs More Screening? Flowchart
This popular screening decision support tool for health providers has just been updated, view it HERE.

CEM Study
A retrospective, single-institution study at Memorial Sloan Kettering Cancer Center reported results of several rounds of screening contrast-enhanced mammography (CEM) in 609 women with extremely dense breasts, most of whom also had other risks for breast cancer. Compared to low-energy images (similar to a standard 2D full-field digital mammogram), contrast enhancement:

  • Increased cancer detection1
  • Decreased specificity, which improved at follow up exams when prior images were available for comparison2

As summarized in an accompanying editorial by Marc Lobbes, MD, PhD, these results support the use of CEM as a safe and effective screening tool for women with dense breasts.

1The cancer detection rate after contrast enhancement vs. low-energy images was 12.7 per 1000 (16/1264) vs. 4.0 per 1000 (5/1264) for an incremental cancer detection rate of 8.7 per 1000 screens (11/1264). The sensitivity after contrast enhancement vs. the low energy images was 88.9% (95% CI: 65.3, 98.6) vs. 27.8% (95% CI: 9.7, 53.5) (P = .003).

2The specificity after contrast enhancement vs. low-energy images was 88.9% vs. 96.2%, P < .001. Specificity at follow-up improved to 90.7% (95% CI: 88.5, 92.7; P = .01).

Research Round Up

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AI vs. ultrasound
A single-institution, retrospective study of 5707 women with dense breasts and a negative mammogram at Seoul National University Hospital found that adding artificial intelligence (AI) is less effective than adding screening ultrasound (US). Supplemental physician-performed whole breast handheld US found more cancers than 2D digital mammography (MG) plus AI with an added incremental cancer detection rate of 2.2 (95% CI 1.1, 3.8) per 1000 screens. All 12 additional cancers seen by US alone were invasive and node negative. While sensitivity was higher for MG plus US than for MG plus AI  (97% vs. 60%, p=.002), specificity was lower (77.6% vs. 95.3%, p<.001). Further research is needed to better understand the role of AI in women with dense breasts.

Contrast-enhanced mammography
Patel and colleagues at Mayo Clinic, Scottsdale, AZ, reported results of the first round of screening contrast-enhanced mammography (CEM) after negative digital breast tomosynthesis (DBT) in 460 women at elevated risk, of whom 408 (89%) had dense breasts. CEM prompted biopsy in 37 (8.0%) women, with 11/37 (30%) found to have cancer, for a supplemental cancer detection rate of 24/1000. Specificity of CEM was 393/449 (87.5%). Of 14 total malignancies found, 10 were invasive, median size 9 mm, all node negative; there was one interval cancer found on screening MRI.

NEW Technology Tab Table

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New – updated table for health professionals, Cancer Detection by Screening Method in Dense Breasts. By modality, the table shows results of supplemental screening after mammography in dense breasts in first and subsequent rounds of screening. It includes the added cancer detection benefit, change in false positive recall rate, and availability.

As a reminder, patient content on the topic is also available in DBI’s new very popular page Screening Tests After a Mammogram.

New Studies

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Recently Published

Two recently published studies that might be of interest –

Patient Experience of Women with Dense Breasts Undergoing Screening Contrast-Enhanced Mammography:
A study from the University of Virginia, co-authored by DBI medical advisory board member Dr. Jennifer Harvey, found that most women with dense breasts who underwent contrast-enhanced mammography reported a positive experience. Over 90% reported minimal or no unpleasantness, indicated they would probably undergo CEM in the future if the cost was similar to a traditional mammogram, and that they would very likely recommend it to a friend.

AI-based selection of individuals for supplemental MRI in population-based breast cancer screening: the randomized ScreenTrustMRI trial:
A randomized study conducted by researchers at the Karolinska Institute found that using AI to select women for supplemental MRI screening rather than density alone resulted in 4 times as many cancers detected by MRI (64 vs. 16.5 per 1000). Selecting women based on a high AI score was cost effective, resulting in a cost per cancer detected similar to screening mammography.  This study will ultimately report on the effect of MRI (if any) on reducing advanced breast cancers, including interval cancers.

New State Insurance Laws

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State Insurance Laws
NEWS on insurance laws for expanded breast imaging in Louisiana, Mississippi, New Hampshire, and Nevada. Currently, 32 states + DC have insurance laws for expanded coverage for either screening or diagnostic imaging. Alaska may be next – that bill is on the governor’s desk – stay tuned!

  • Full details by state HERE
  • Insurance map visual HERE

Amended “Inform” Law, New Study

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Rhode Island Density Inform Law Amended
In preparation for the FDA’s new dense breast reporting standard going into effect Sept 10, 2024, Rhode Island has amended its existing “inform” law. The Rhode Island inform law will now defer to the FDA’s national reporting standard. Please see DBI’s State Law Map or Table for details.  As previously mentioned, existing state density inform laws may remain in effect in addition to the FDA requirement unless that state law specifically defaults to the new FDA standard, expires, or is repealed.

Just Published
A retrospective study just out in Radiology,  Comparison of Mammography and Mammography with Supplemental Whole-Breast US Tomography for Cancer Detection in Patients with Dense Breasts, evaluated the performance of US tomography (UST)  combined with full-field digital mammography (FFDM) in a reader study in women with dense breasts. The addition of UST improved cancer detection over FFDM alone and the detection rate was comparable to other ultrasound screening methods.

Review Article

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Newly Published
New review article out The paradox of MRI for breast cancer screening: high-risk and dense breasts—available evidence and current practice details the evidence supporting screening MRI for women with dense breasts. Should the evidence be enough for guidelines and implementation? As a reminder, in Europe, EUSOBI’s most recent screening recommendations call for supplemental MRI or ultrasound for women with category C or D (dense) breasts, with an explicit recommendation of MRI at a minimum of every 4 years for women with extremely dense breasts.  In the USA, the American College of Radiology states “For women with dense breasts who desire supplemental screening, breast MRI is recommended.”

NEW Patient Technology Info

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NEW! Screening Technology Info for Patients
The FDA requirement for density inform is around the corner, and with it will come new patient/provider conversations about what it means and what to do. To gear up, DBI has developed simplified, introductory content for patients, Screening Tests After a Mammogram. We extend thanks to our hardworking Patient Advisory Group who devoted much time and input into its development. Please visit and share the new page!

Breast Cancer Screening Updates from Canada

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While Canadian breast cancer screening advocates celebrated the Canadian Cancer Society’s endorsement of lowering the screening age to 40, unfortunately the soon-to-be-released Canadian Task Force guidelines are unlikely to do the same. Ten out of twelve provinces with screening programs have lowered the screening age to 40, but it is still important that the Task Force do so as well, since Task Force guidelines would inform primary care providers who often discourage breast screening until the age of 50. Despite the increasing incidence of women in their 40s presenting with advanced breast cancers, the Task Force does not seem poised to lower the recommended screening age.

TOCEM Interim Analysis

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Just Published in Radiology
Addition of Contrast-enhanced Mammography to Tomosynthesis for Breast Cancer Detection in Women with a Personal History of Breast Cancer: Prospective TOCEM Trial Interim Analysis. Women with a personal history of breast cancer are at higher risk for second cancers and for having that cancer missed on mammography. Interim analysis from the ongoing TOCEM study, led by DBI Chief Scientific Advisor Dr. Berg, shows very favorable results using annual screening contrast-enhanced mammography (CEM) after tomosynthesis, with added cancer yield of 7/1000 in year 1 and 4/1000 in years 2 and 3, small median invasive tumor size of 0.6 cm, mostly node negative. Added recalls occurred in 6.6% women year 1 and 5% in subsequent years.

Canada Inform, ILC Imaging, Research Grant

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Density Inform / Canada
Good news from DenseBreastsCanada! Dense breast notification from coast to coast goes into effect this summer in Canada! Well done to advocates Jennie Dale and MAB member Dr. Paula Gordon for their tireless efforts.

JBI Article on Imaging for ILC
In an article co-authored by MAB members Drs. Wendie Berg and Lars Grimm, the majority of SBI member radiologists surveyed felt that additional screening beyond mammography was needed to detect ILC in dense breasts, to image extent, and in women of all breast densities with treated ILC.

New Research Grant
Congratulations to Dr. Wendie Berg on the award of a research grant from the PA Breast Cancer Coalition as co-PI with Dr. Shandong Wu to study the use of AI added to contrast-enhanced mammography to reduce false positives in screening!

Updated Technology Tab Info, New Co-Educator

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Screening Technologies Update
DBI’s Screening Technologies tab has just been updated! For easy reference, each updated modality section now includes “Quick Facts” bullets in the introduction. Many thanks to our hard-working Medical Advisory Board for their editorial input.

Coming soon: The new FDA dense breast reporting standard goes into effect in September and will result in new patient/provider conversations about supplemental screening. To help inform patients about supplemental screening options, DBI will be launching a dedicated patient-friendly screening technology section. Stay tuned!

New Education Co-Educator
Service Women’s Action Network (SWAN) is “the voice of all military women” including the 350,000 active service women and 2 million women veterans in the U.S. We welcome SWAN to our Education Coalition and are honored the organization now includes DBI as a resource for members: https://www.servicewomensactionnetwork.org/obgyn

Illinois Insurance Bill, Health Provider FAQs

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U.S. State Insurance Bill
The state of Illinois has introduced insurance bill HB4180 for expanded mammography coverage and expanded supplemental screening (for no-cost MBI or MRI). For information about IL’s existing insurance laws, please visit DBI’s legislation MAP.

Health Provider FAQs
Did you know? The DenseBreast-info.org website features 50+ health provider FAQs, and answers include relevant research citations.

U.S. State Insurance Bill, Canadian Province Breast Screening Bill

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U.S. Insurance Bill
Michigan has introduced bill HB5084 for expanded insurance coverage of screening and diagnostic breast imaging. For state-by-state information about inform and insurance laws, visit DBI’s legislation MAP.

Canadian Provincial Bill
The province of Nova Scotia has introduced Bill 356 that calls for women with dense breasts to have supplemental cancer screening such as an ultrasound or magnetic resonance imaging (MRI). For info by Canadian province on density “inform” and supplemental screening programs, please visit DenseBreastsCanada.

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