Screening

NEWS:  Who Needs More Screening? flowchart update

• Our hard-working Medical Advisory Board has updated one of DenseBreast-info.org’s most frequently referenced tools. The  Who Needs More Screening? flowchart* has been updated to include risk assessment by age 30 and expanded the indications for supplemental MRI. It takes into consideration updates to NCCN guidelines and the recent publications from the DENSE trial and EA1141 (Comparison of Abbreviated Breast MRI and Digital Breast Tomosynthesis in Breast Cancer Screening in Women with Dense Breasts).
• For those referencing or sharing the flowchart, please discontinue use of any prior version. Please contact us for direction on the update.

*European visitors, to access from DB-i/EU homepage, select Home/USA, then “For Health Professionals, tab” and then “Flow Chart” in the dropdown menu. An update to the EU screening flowchart will follow. 

COVID and Screening

• DB-i’s Chief Scientific Advisor, Dr. Wendie Berg, authored an article for the Breast Cancer Research Foundation, Breast Cancer Screening and COVID-19: What Patients Need to Know

#DenseBreastDay™
The Sept 30^th online education day, organized in conjunction with Yale Medicine, resulted in “likes”, shares and comments from patients, health providers and health organizations from across the globe. DB-i website visits exceeded 1,000 for the day.  Many thanks to our corporate Educational Supporters for their participation. We are still compiling social media analytics, stay tuned!

Australia: Density Inform and Education
A new patient video produced by InforMD, an alliance of Australian breast cancer researchers advancing knowledge on breast density, has been launched: https://www.youtube.com/watch?v=EZHjEFGEtaA

Diversity in Screening Implications
A new webinar from the Hawaii Radiological Society and an article published in the Journal of Breast Imaging are just out on the topic:

• Hawaii Radiological Society Women and Diversity Committee Webinar on Breast Cancer Health Disparities
• Article: Breast Cancer Screening Recommendations: African American Women Are at a Disadvantage

New Study
In a recent publication in Radiology, researchers from the Karolinska Institutet in Sweden used AI to analyze breast density, presence of masses and calcifications, and differences between right and left breasts to successfully predict women who would develop interval cancer or advanced cancer in the two years after a normal mammogram; their model proved more accurate than traditional risk models and can augment genetic/family history to help identify women who should and, importantly, who should not have supplemental screening after 2D mammography.

Breast Cancer Awareness Month Reminders
In support of #BCAM, DB-i has launched an education initiative for both the patient and health provider communities:

#DenseBreastDay™ is this Wednesday, Sept 30th. It will be a full day social media blitz for the general public hosted in conjunction with Yale Medicine. Educational tweets will be posted every half hour, please share! Europe-specific content tweets and posts in Spanish are included in the day’s schedule.

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:

• Women with known or disease-causing BRCA1 mutation (or their untested first-degree relatives) should begin annual MRI at age 25. If MRI is performed annually, there is emerging evidence that the benefit of mammography is relatively small in such women prior to the age of 40.
• Women with other known disease-causing mutations (or their untested first-degree relatives), and those with a calculated lifetime risk of 20% or more, should begin annual MRI between age 25 and 30. Annual mammography is of benefit in those with BRCA2 mutations.
• Women with prior chest/mantle radiation therapy (cumulative dose of ≥ 10 Gy) before age 30 should begin MRI and annual mammography at age 25 or at least 8 years after completion of radiation, whichever is latest.
• Women with a calculated lifetime risk of breast cancer of ≥ 20%. The Tyrer-Cuzick model was discussed as the most comprehensive and consistently accurate model for predicting risk and now includes breast density as a risk factor, though all models may over- or underestimate risk for a given individual.

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):

• Women with a personal history of breast cancer and dense breasts.
• All women diagnosed by age 50. A personal history of breast cancer is not included in risk models, but all women diagnosed with breast cancer at or before age 50 and treated with breast-conserving therapy have a ≥ 20% risk for a new breast cancer.

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.

1. Monticciolo DL et al. J Am Coll Radiol. 2018 Mar;15(3 Pt A):408-414. doi: 10.1016/j.jacr.2017.11.034. Epub 2018 Jan 19.

2. Stapleton SM, Oseni TO, Bababekov YJ, Hung Y, Chang DC. Race/Ethnicity and Age Distribution of Breast Cancer Diagnosis in the United States. JAMA Surg. Published online March 07, 2018. doi:10.1001/jamasurg.2018.0035