For every 1000 women having a 2D screening mammogram, about 100 (10%) will be called back (“recalled”) for additional testing. About 2-7 breast cancers will be found [1, 2].
Breast cancer risk increases with increasing age. For women in their 40s, 2 cancers will be found for every 1000 screening mammograms performed. Those 1000 mammograms also result in 120-140 “false positive” recalls (additional testing for findings that don’t prove to be cancer). For women over age 75, cancer detection rates average 6-7 for every 1000 screening mammograms and false positive recalls average 55-65 per 1000 [1].
With increasing age, there are more cancers to be found, but they are easier to find and there are fewer false positive recalls. They are easier to find because breasts often become less dense around menopause. There are fewer false positive recalls because there are previous exams (like mammograms, ultrasounds or MRI) available for comparison.
Cancers found because of a lump or other symptoms after a normal screening mammogram and before the next routine screening are called “interval cancers.” In the United States, the time period between screens is typically one year, in most of Europe it is two years, and in the United Kingdom, three years. Interval cancers tend to grow faster and have worse outcomes than screen-detected cancers. They are also more common in women with dense breasts, and occur more often if there is a longer time period between screens. Some supplemental screening methods (used after mammography), such as MRI or ultrasound, have been found to reduce the number of interval cancers; other supplemental screening methods likely do too.
Results from supplemental screening after standard 2D mammography are summarized in the table.
| Method | Breast Density | Added Cancer Detection | Change in False Positive Recall Rate (from 2D 100-120 per thousand)a | Interval Cancers Reduced | Availabilityb |
|---|---|---|---|---|---|
| Tomosynthesis (3D mammography)c | Heterogeneously or Extremely dense | Average 2 per 1000 (range 1 - 3 per 1000) [3-6]d | -32 per 1000e (range -2 to -84 per 1000) [3-6] | Possiblyf [7, 8] | Widespread |
| Ultrasound (first round)g | Heterogeneously or Extremely dense | 2 - 3 per 1000 [9] | +75 to 117 per 1000 [9, 10] | Yes [11-13] | Moderate |
| Ultrasound (subsequent rounds) | Heterogeneously or Extremely dense | 3 - 4 per 1000 [10, 11] | +70 to 98 per 1000 [10, 11] | Yes | Moderate |
| Ultrasound after tomosynthesis | Heterogeneously or Extremely dense | 2 - 3 per 1000 [14, 15] | Increase in false positive recalls with USh | Unknown | Moderate |
| MBI | Heterogeneously or Extremely dense | 7 - 9 per 1000 [16-18] | +54 to 77 per 1000 [16-18] | Unknown | Limited |
| Contrast-Enhanced Mammography | Heterogeneously or Extremely dense | Average 10 per 1000 (range 7 - 13 per 1000) [19-22]i | +65 per 1000 (range +29 to +144 per 1000) [19-22] | Unknown | Limited |
| MRI/Abbreviated MRI (first round) | Heterogeneously or Extremely dense | Average 16 per 1000 (range 10 – 20 per 1000) [11, 23, 25, 26] | +103 per 1000 (range +80 to +215 per 1000) [11, 23, 25] | Yes | Moderate for high-risk women |
| All densities | Average 17 per 1000 (range 10 – 25 per 1000) [11, 23, 25-27] | +87 per 1000 (range +42 to +215 per 1000) [11, 23, 25-27] | Yes | Moderate for high-risk women |
|
| MRI (subsequent rounds) | All densities | Average 6 per 1000 (range 6 – 7 per 1000) [24, 26] | +23 per 1000 (range +16 to +26 per 1000) [24, 26] | Yes | Moderate for high-risk women |
a Ranges provided for added cancer detection and change in false positive recall rate estimates account for differences in estimates from studies. Differences in estimates are due to differences in study design, methods, patient populations studied, and frequency of screening.
b Relative availability listed is for the United States. For European practice by country, see: https://densebreast-info.org/europe/map-screening-guidelines
c 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.
d Results from Osteras et al. [6] are reported at the breast level and inferred at the participant level.
e Tomosynthesis has been shown to reduce the recall rate by an average of 32 per 1000 women screened compared to 2D mammography.
f One study showed a slight reduction in interval cancer rates for tomosynthesis compared to standard mammography overall [7], which was not specific to density category; however, most studies have not shown a reduction in interval cancer rates [8].
g Performance characteristics of screening ultrasound are similar with handheld ultrasound, automated ultrasound, and semi-automated ultrasound [9].
h In the Italian multicenter ASTOUND-2 trial, ultrasound increased recalls more than tomosynthesis (1.0% vs. 0.3%) after a negative 2D mammogram, but absolute recall rates are not comparable to those in the United States.
i When comparing added cancer detection from CEM to that from MRI, the following should be considered: No screening studies compared CEM to MRI in the same women; MRI screening intervals differed between studies (one year vs. two); and study populations, risk factors, and study designs differed. In addition, two of the four studies used to estimate the CEM added cancer detection rate included a proportion of women who underwent multiple screens at varying intervals; therefore, it may be most appropriate to compare the CEM added cancer detection rate to the overall rate for first and subsequent MRI rounds combined which would be about 13 per 1000 screens.
References Cited:
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