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Screening

DBI Study and Article, New Research

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In Case You Missed it
Two DBI initiatives on risk assessment and supplemental screening published in the Journal of Breast Imaging continue to be popular:

Just Published
Out in Radiology, Comparative Performance of Contrast-enhanced Mammography, Abbreviated Breast MRI, and Standard Breast MRI for Breast Cancer Screening. Performance metrics were compared between pooled CEM and AbMRI evaluations from 246 participants (492 interpretations respectively) and 246 standard MRI evaluations from a single reader abstracted from the medical record. While the study found that the cancer detection rate and sensitivity of CEM was lower compared with standard MRI, importantly, readers were trained on CEM just prior to the study whereas MRI was used during the reader’s regular clinical practice. Differential experience interpreting CEM vs. MRI may have resulted in detection bias impacting the findings and pointing to the need for more radiologist training before widespread CEM use.

DENSE Trial 

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A study of women with extremely dense breasts, the Dutch DENSE trial, has shown that adding MRI to mammography every two years improves cancer detection and reduces interval cancer rates. In a secondary analysis published in Radiology, women in the top third of enhancing volume of breast tissue on MRI were twice as likely to develop breast cancer as those in the lowest third. As incoming DBI MAB member Dr. Lars Grimm points out in an accompanying editorial, it is important to consider combinations of breast density and other risk factors that qualify women as “high risk” and therefore eligible for continued screening MRI under current guidelines.

NCCN Updates; South Australia News

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South Australia
Breast Screen SA has announced that beginning August 8th 2023, South Australian women will be informed, in all screening clinics, of their individual breast density category.

 Screening flowchart
The Who Needs More Screening? flowchart has been updated to incorporate the recently released NCCN guidelines. The flowchart provides a roadmap for screening women with dense breasts or at higher risk and represents the consensus opinion of our Medical Advisory Board.

Density “Inform” in Canada

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News Out of Canada
Ontario, Canada’s most populated province, has become the 7th province to require notification about breast density to women after screening mammography. Women will be informed of their specific density category (A, B, C or D) and the associated risks. Further, a draft recommendation to provide supplemental screening for women in category D (extremely dense breasts) is expected to be finalized in the Fall.

Two additional provinces, Saskatchewan and Newfoundland/Labrador have also committed to begin density notification in 2023. That will bring the total number of provinces with some level of density “inform” requirement to 9 (out of 10).  Please visit DenseBreastsCanada.ca for more info.

Find It Early Act (HR 3086)

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A reminder that The Find It Early Act needs your support. This bill would ensure that all U.S. health insurance plans cover screening and diagnostic breast imaging with no out-of-pocket costs for women with dense breasts or at higher breast cancer risk. Your congressperson would benefit from hearing your perspective about the legislation. In-person visits or phone calls from constituents are motivating to elected officials. And, representatives that sign on as bill co-sponsors help the bill’s momentum.

Please take action: See DBI’s Find It Early Act webpage for “Lobbying 101” info on how to contact a congressperson, how to schedule a meeting, what to bring, what to ask, and follow up suggestions.

New RI Insurance Law & More

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U.S. State Insurance Law
A new insurance law for expanded breast imaging has been signed into law in Rhode Island (copays/deductibles apply). Please see DBI’s Legislative Info tab for updated details.

Just Published
New in JACR, authored by DBI’s Chief Scientific Advisor Dr Wendie Berg, Analytic Hierarchy Process Analysis of Patient Preferences for Contrast-Enhanced Mammography (CEM) versus MRI as Supplemental Screening Options for Breast Cancer. The study showed that 70% of women who had both CEM screening and MRI preferred CEM. 97% of women with claustrophobia favored CEM. For women for whom positioning was most important, only 54% favored CEM. Healthcare providers should include discussion of these factors as part of shared decision making with patients desiring supplemental screening.

Educational Opportunities

  • The Association for Medical Imaging Management (AHRA) 50th anniversary annual meeting –  Executive Director JoAnn Pushkin’s presentation, Dense Breasts: New FDA Reporting Standard, Insurance Laws, Educational Tools, will be on Sunday July 9th.
  • In collaboration with the National Women’s Health Network (NWHN), DBI will participate in webinar Find It Early, on Friday July 14th from 12:00-1:00pm/EST. Keynote Speaker Rep. Rosa DeLauro, sponsor of the Find it Early Act, will be joined by DBI’s JoAnn Pushkin and NWHN’s Denise Hyater-Lindenmuth.

Updated Screening Flowchart & Recently Published

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Who Needs More Screening? 
Just updated! One of the most popular DBI website tools is the screening decision support flowchart Who Needs More Screening?. The flowchart has just been updated and can be found in the For Providers tab. In the absence of national screening guidelines for women with dense breasts or at higher risk, the flowchart provides a roadmap and represents the consensus opinion of our Medical Advisory Board.
 
Recently Published 
Analysis of over 2.6 million mammogram results from the Breast Cancer Surveillance Consortium confirms greater prevalence of dense breasts in Asian women (66%) than non-Hispanic (NH) White women (45%), Hispanic women (45%), or Black women (37%). Breast density is inversely related to body mass index (BMI) and decreases with age and menopause. After correcting for BMI, age, and menopausal status, Black women were more likely to have dense breasts than NH White or Hispanic women. https://www.ncbi.nlm.nih.gov/pubmed/37284771

Nebraska insurance law, Just published

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State Insurance Law
Legislation for expanded breast imaging insurance coverage has been signed into law in Nebraska. Please see DBI’s Legislative Info for updated map and table details.

Just Published
In Cancer, coauthored by DBI MAB member Dr Sally Herschorn, Breast cancer risk characteristics of women undergoing whole-breast ultrasound screening versus mammography alone.  Many women at high risk of screening mammography failure do not currently undergo supplemental screening beyond mammography.  Health care provider and patient awareness of other breast cancer risk factors beyond breast density, including family history and prior benign biopsies, is important in identification of women at high risk of mammography screening failure (interval cancer or advanced breast cancer) who should be recommended for supplemental screening with ultrasound or especially MRI. It is important to recognize that limiting supplemental screening to women at intermediate- to high-risk by the BCSC model would fail to identify 30-40% of women with dense breasts who will experience interval cancer and about 60% of all women who will develop advanced breast cancer.

Canadian Task Force Guidelines, Of Interest

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Canada
The Canadian Task Force, Canada’s source of evidence-based clinical prevention guidelines for primary care providers, just announced it is “fast tracking” updates to their 2018 breast cancer screening guideline. Draft recommendations are due in late fall 2023.

Of Interest

USPSTF, ACR Recommendations, U.S. Insurance Legislation

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United States Preventive Services Task Force (USPSTF)
USPSTF updated screening guidelines updates were just published and now include the recommendation that mammography screening in normal risk women occur every other year beginning at 40 (was 50).  Unfortunately, for women with dense breasts, the recommendations incorrectly conclude there is “inadequate” evidence to support adding supplemental screening ultrasound or MRI after a mammogram and fail to recognize the important of annual screening.

2023 ACR Screening Recommendations for Women at Higher Risk
New recommendations just published! For women at higher-than-average risk of breast cancer, the ACR recommends annual digital mammography, beginning between ages 25 and 40, and supplemental screening, depending on risk, with breast MRI as the supplemental method of choice. Notably, women with extremely dense breasts are considered to have approximately twice the “average” risk, and for women with dense breasts who desire supplemental screening, breast MRI is recommended.

Federal Bill, the Find It Early Act
The federal insurance bill, the Find It Early Act, has been re-introduced in this session of Congress by Reps. DeLauro and Fitzpatrick. Their announcement HERE.

New U.S. State Insurance Laws
Insurance coverage for breast imaging has been signed into law in:

  • Pennsylvania (Act 1 of 2023). The law provides for “all costs associated with one supplemental breast screening every year if a woman is believed to be at an increased risk of breast cancer” due to specified reasons. The law also provides coverage for BRCA-related genetic counseling and genetic testing.
  • Maryland (Chapter 0298). The law prohibits, “… except under certain circumstances, insurers, nonprofit health service plans, and health maintenance organizations that provide coverage for diagnostic and supplemental breast examinations from imposing a copayment, coinsurance, or deductible requirement for the examination.”

For more details, please visit the DBI Legislative Information tab.

Journal of Breast Imaging

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An article is just out in JBI  “Implementing the National Dense Breast Reporting Standard, Expanding Supplemental Screening Using Current Guidelines, and the Proposed Find It Early Act” authored by DBI’s Dr. Wendie Berg, Dr. Robin Seitzman, and JoAnn Pushkin. One of the conclusions is, “With a new national standard for density notification, breast imaging radiologists and centers should be preparing. Development of a protocol for evaluating the need for, and recommendation of, supplemental screening, and ways to facilitate orders from their referring physician community are opportunities.”

Website Update

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As new research is published, the DBI website content is reviewed and edited, including:

New Research

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Just published in Journal of Clinical Oncology, a case-cohort study, Long-Term Performance of an Image-Based Short-Term Risk Model for Breast Cancer. Conducted at Karolinska Institutet, the study showed an image-based risk model developed to predict short-term breast cancer risk can also be used to assess long-term risk for identifying women who may benefit from risk-reducing strategies and supplemental screening. The image-based model showed better accuracy in predicting 10-year risk than the Tyrer-Cuzick v8 model, a traditional lifestyle/familial-based risk model.

2D vs 3D Mammography and More

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New Research
DBI Medical Advisory Board member Dr. Emily Conant is lead author on Mammographic Screening in Routine Practice: Multisite Study of Digital Breast Tomosynthesis and Digital Mammography Screenings. The findings indicate that women undergoing digital breast tomosynthesis had higher cancer detection rates, higher positive predictive value, and lower recall rates compared with women who underwent digital mammography. Consistent with other studies, the study found improved cancer detection rates for women with heterogeneously or extremely dense breasts using 3D.  Recall rates were reduced in heterogeneously dense breasts but not in extremely dense.

Europe
DBI’s European Education Coordinator Cheryl Cruwys has been active educating on the implications of dense tissue and sharing DenseBreast-info.org/Europe resources:

Federal Legislation, New Publication

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Want to get involved?  Check the Find It Early Act webpage for information on how to contact a congressperson, how to schedule a meeting, what to bring, what to ask, and follow up suggestions. This “Lobbying 101” page was developed with feedback from Rep. Rosa DeLauro’s office on best practices and input from our Patient Advisory Group on language.

Newly Published
Out in Radiology, Supplemental Breast Cancer Screening in Women with Dense Breasts and Negative Mammography: A Systematic Review and Meta-Analysis with accompanying editorial by MAB member Dr Regina Hooley. In a meta-analysis of 3D mammography, ultrasound, or MRI to supplement 2D mammography, Hussein et al report results consistent with the literature that screening MRI outperforms anatomic imaging in cancer detection. MRI found 26 cancers per 1000 women screened, with acceptable PPV of biopsy.  Not all women can tolerate MRI, however, and, in their analysis, supplemental screening with either handheld or automated US found 4 cancers per 1000 women screened that were missed on mammography.

Updates in the U.S. and Europe

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U.S. State Density Inform Bill and Insurance Bills
West Virginia has introduced two density “inform” bills; please see DBI’s updated legislation MAP for details. And, insurance bill introductions requiring coverage for expanded breast imaging continue with 20+ bills so far!

Europe: Screening Guidelines
Greece now has a national (organized) screening program. Please find updated information by country in our European Screening Guidelines MAP and TABLE.

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