For every 1000 women screened with 2D mammography, approximately 100-120 women will be recalled for additional testing and 2-7 women (depending on the age and risk factors of the woman) will be found to have breast cancer [1, 2].
Breast cancer incidence increases as women get older: for women in their 40s, cancer detection rates on mammography are closer to 2 per 1000 and “false positive” recalls (additional testing for findings that do not prove to be cancer) are 120-140 per 1000. With increasing age, cancer detection rates increase and false positive recalls decrease (in part because prior mammograms are available for comparison and in part because breasts often become less dense and have a less complex texture as women get older). For women over age 75, cancer detection rates average 6-7 per 1000 and false positive recalls average 55-65 per 1000 [1].
With any screening method, false positive recalls are almost always reduced when prior examinations are available for comparison, i.e. in subsequent or “incident” screening rounds.
Cancers found as a lump or because of other symptoms in the interval between breast screenings are called “interval cancers.” The screening interval in the United States is typically one year, in most of Europe it is two years, and in the United Kingdom, three years. Interval cancers tend to be more aggressive with worse outcomes than screen detected cancers, and are more likely in women with dense breasts and more frequent with longer screening intervals. Some supplemental screening methods have been found to reduce the occurrence of interval cancers, and further study is needed for others.
The Table below shows a summary of the expected additional cancer detection (in women of different breast density), effect on the false positive recall rate, and impact on interval cancer reduction using screening imaging methods after standard 2D mammography.
| Method | Breast Density | Added Cancer Detection | Projected change in False Positive Recall Rate (from 2D 100-120 per thousand) | Evidence Interval Cancers Reduced | Availability* |
|---|---|---|---|---|---|
| Tomosynthesis (3D mammography)a | Scattered fibroglandular density or Heterogeneously dense | 1-2 per 1000 [3-5] | -15 to -44 per 1000b [3-5] | Possiblyc [6, 7] | Widespread |
| Tomosynthesis (3D mammography)a | Extremely dense | Negligible [3, 8, 9] | No significant reduction [3, 8, 9] | No | Widespread |
| Ultrasound (US) (first round)d | Heterogeneously dense or Extremely dense | 2-3 per 1000 [10] | +75 to 117 per 1000 [10, 11] | Yes [12-14] | Moderate |
| Ultrasound (US) (subsequent rounds) | Heterogeneously dense or Extremely dense | 3-4 per 1000 [11, 12] | +70 to 98 per 1000 [11, 12] | Yes | Moderate |
| Ultrasound after tomosynthesis | Heterogeneously dense or Extremely dense | 2-3 per 1000 [15, 16] | Increase in false positive recalls with USe | Unknown | Moderate |
| MBI | Heterogenously or Extremely dense | 7-9 per 1000 [17-19] | +54 to 77 per 1000 [17-19] | Unknown | Limited |
| Contrast-Enhanced Mammograpy | Heterogeneously or Extremely dense | 8-13 per 1000 [20, 21] | +34 to 144 per 1000f [20, 21] | Unknown | Limited |
| MRI (first round) | Extremely dense | 16 per 1000 [22] | +80 per 1000 [22] | Yes | Moderate for high-risk women |
| MRI (subsequent rounds) | Extremely dense | 6 per 1000 [23] | +26 per 1000 [23] | Yes | Moderate for high-risk women |
| Abbreviated (“fast” or “mini”) MRI after tomosynthesisg | Heterogeneously dense or Extremely dense | 10 per 1000 [24] | +107 per 1000 [24] | Expected | Limited © DenseBreast-info.org and Dr. Wendie Berg |
*Relative availability listed is for the United States. For European practice by country, see: https://densebreast-info.org/europe/map-screening-guidelines
DCIS = ductal carcinoma in situ
a In many centers, a “standard” 2D mammogram can be created from the same projection images used to generate the tomosynthesis (“synthetic” 2D mammogram) so that there is no added radiation or second exposure for the 2D mammogram.
b Tomosynthesis has been shown to reduce the recall rate by an average of 20 per 1000 women screened compared to 2D mammography.
c One study showed a slight reduction in interval cancer rates for tomosynthesis compared to standard mammography overall [6], which was not specific to density category; however, most studies did not show a reduction in interval cancer rates [7].
d Performance characteristics of screening ultrasound are similar with handheld ultrasound, automated ultrasound, and semi-automated ultrasound.
e In the Italian multicenter ASTOUND-2 trial, ultrasound increased recalls more than tomosynthesis (1.0% vs. 0.3%) after a negative 2D mammogram, but recall rates are not comparable to those in the United States.
f Data are from two series [20, 21]. Cancer findings are shown for the 700 women with dense breasts in the series evaluated by Sung et al. [20]. Recall rates include false-positive and true-positive recalls for all 904 women as results were not distinguished for the subset of women with dense breasts.
g In this prospective trial across 48 centers in the United States and Germany, abbreviated MRI was compared to tomosynthesis (3D mammography).
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