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 .
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 ||+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 ||+80 per 1000 ||Yes||Moderate for high-risk women|
|MRI (subsequent rounds)||Extremely dense||6 per 1000 ||+26 per 1000 ||Yes||Moderate for high-risk women|
|Abbreviated (“fast” or “mini”) MRI after tomosynthesisg||Heterogeneously dense or Extremely dense||10 per 1000 ||+107 per 1000 ||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 , which was not specific to density category; however, most studies did not show a reduction in interval cancer rates .
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. . 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).
1. Lee CS, Sengupta D, Bhargavan-Chatfield M, Sickles EA, Burnside ES, Zuley ML. Association of Patient Age With Outcomes of Current-Era, Large-Scale Screening Mammography: Analysis of Data From the National Mammography Database. JAMA oncology2017; 3:1134-1136
2. Lehman CD, Arao RF, Sprague BL, et al. National Performance Benchmarks for Modern Screening Digital Mammography: Update from the Breast Cancer Surveillance Consortium. Radiology. 2017;283(1):49-58
3. Rafferty EA, Durand MA, Conant EF, et al. Breast Cancer Screening Using Tomosynthesis and Digital Mammography in Dense and Nondense Breasts. JAMA 2016; 315:1784-1786
4. Skaane P, Bandos AI, Niklason LT, et al. Digital Mammography versus Digital Mammography Plus Tomosynthesis in Breast Cancer Screening: The Oslo Tomosynthesis Screening Trial. Radiology2019; 291:23-30
5. Conant EF, Zuckerman SP, McDonald ES, et al. Five Consecutive Years of Screening with Digital Breast Tomosynthesis: Outcomes by Screening Year and Round. Radiology2020:191751
6. Johnson K, Lang K, Ikeda DM, Akesson A, Andersson I, Zackrisson S. Interval Breast Cancer Rates and Tumor Characteristics in the Prospective Population-based Malmo Breast Tomosynthesis Screening Trial. Radiology 2021; 299:559-567
7. Houssami N, Hofvind S, Soerensen AL, et al. Interval breast cancer rates for digital breast tomosynthesis versus digital mammography population screening: An individual participant data meta-analysis. EClinicalMedicine 2021; 34:100804
8. Yi A, Chang JM, Shin SU, et al. Detection of noncalcified breast cancer in patients with extremely dense breasts using digital breast tomosynthesis compared with full-field digital mammography. Br J Radiol2018:20180101
9. Osteras BH, Martinsen ACT, Gullien R, Skaane P. Digital Mammography versus Breast Tomosynthesis: Impact of Breast Density on Diagnostic Performance in Population-based Screening. Radiology2019; 293:60-68
10. Berg WA, Vourtsis A. Screening breast ultrasound using hand-held or automated technique in women with dense breasts. J Breast Imaging2019; 1:283-296
11. Weigert JM. The Connecticut Experiment; The Third Installment: 4 Years of Screening Women with Dense Breasts with Bilateral Ultrasound. Breast J2017; 23:34-39
12. Berg WA, Zhang Z, Lehrer D, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA2012; 307:1394-1404
13. Corsetti V, Houssami N, Ghirardi M, et al. Evidence of the effect of adjunct ultrasound screening in women with mammography-negative dense breasts: interval breast cancers at 1 year follow-up. Eur J Cancer 2011; 47:1021-1026
14. Harada-Shoji N, Suzuki A, Ishida T, et al. Evaluation of Adjunctive Ultrasonography for Breast Cancer Detection Among Women Aged 40-49 Years With Varying Breast Density Undergoing Screening Mammography: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2121505
15. Tagliafico AS, Calabrese M, Mariscotti G, et al. Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts: Interim Report of a Prospective Comparative Trial. J Clin Oncol2016; 34:1882-1888
16. Tagliafico AS, Mariscotti G, Valdora F, et al. A prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2). Eur J Cancer2018; 104:39-46
17. Rhodes DJ, Hruska CB, Conners AL, et al. Journal club: molecular breast imaging at reduced radiation dose for supplemental screening in mammographically dense breasts. AJR 2015; 204:241–251
18. Shermis RB, Wilson KD, Doyle MT, et al. Supplemental breast cancer screening with molecular breast imaging for women with dense breast tissue. AJR 2016; 207:450–457
19. Rhodes DJ, Hruska CB, Phillips SW, Whaley DH, O’Connor MK. Dedicated dual-head gamma imaging for breast cancer screening in women with mammographically dense breasts. Radiology 2011; 258:106–118
20. Sung JS, Lebron L, Keating D, et al. Performance of dual-energy contrast-enhanced digital mammography for screening women at increased risk of breast cancer. Radiology 2019; 293:81–88
21. Sorin V, Yagil Y, Yosepovich A, et al. Contrast-enhanced spectral mammography in women with intermediate breast cancer risk and dense breasts. AJR 2018; 211:[web]W267–W274
22. Bakker MF, de Lange SV, Pijnappel RM, et al. Supplemental MRI Screening for Women with Extremely Dense Breast Tissue. N Engl J Med2019; 381:2091-2102
23. Veenhuizen SGA, de Lange SV, Bakker MF, et al. Supplemental Breast MRI for Women with Extremely Dense Breasts: Results of the Second Screening Round of the DENSE Trial. Radiology. 2021 May;299(2):278-286. doi: 10.1148/radiol.2021203633. Epub 2021 Mar 16. PMID: 33724062.
24. Comstock CE, Gatsonis C, Newstead GM, et al. Comparison of Abbreviated Breast MRI vs Digital Breast Tomosynthesis for Breast Cancer Detection Among Women With Dense Breasts Undergoing Screening. JAMA2020; 323:746-756