Supplemental screening sonography in dense breasts

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Basic concepts

Mammographically screen-detected cancers have a better prognosis than clinically detected cancers. Tabar et al [1] found that 50% of screen-detected cancers had good prognosis and 18% had poor prognosis, whereas 19% of clinically detected cancers had good prognosis and 47% poor prognosis. “Good” prognosis cancers include all ductal carcinoma in situ (DCIS), node-negative invasive cancers of small size: less than 20 mm if grade I invasive ductal, less than 15 mm if grade II, less than 10 mm if

MR imaging

MR imaging has been proposed as a supplemental screening examination in high-risk women. Across 11 series [8], 6524 very high-risk (detailed later) women have been screened with MR imaging with 125 (1.9%) women having cancer depicted only on MR imaging. The median size of cancers was 7 to 20 mm, and in all but one series, greater than 80% of MR imaging–only depicted cancers were node negative. Where detailed, 19 (23%) of 81 of the cancers identified were DCIS [8]. Six percent to 18% of women

Single-center studies of screening sonography

Studies of screening sonography to date have been performed in women of average risk with nonfatty breasts. Across six series totaling 42,838 examinations, 150 (0.35%) additional cancers have been identified only on sonography in 126 women (Table 1) [12], [13], [14], [15], [16], [17]. In all but one of these studies [15], a single screening sonogram was performed, which detects prevalent cancers seen only on sonography: there is not an estimate of the rate of incident cancers seen only on

ACRIN Protocol 6666, screening breast ultrasound in high-risk women

With the support of the AVON Foundation and the National Institutes of Health, through the American College of Radiology Imaging Network (ACRIN), a multicenter protocol to assess the efficacy of screening breast sonography has opened to begin enrollment (for more information, go to www.acrin.org) [19]. Twenty centers will enroll 2808 high-risk (Box 1) asymptomatic women with dense breasts for three annual screening mammograms and sonograms. Women will be randomized to initial mammography or

False-positives

One of the advantages of sonography is that biopsy of suspicious abnormalities seen only sonographically is a relatively simple and painless procedure. Nonetheless, minimizing unnecessary patient anxiety and costs is a critical goal of any new screening procedure. Across the single-center studies [12], [13], [14], [15], [16], [17], on average 3.1% of women screened underwent biopsy or aspiration, with 11.4% of biopsied lesions proving malignant (see Table 1).

Short-interval follow-up

Another 6.6% of women required short interval follow-up based on screening sonography [12], [14], [15], [16]. It is important to recognize that criteria continue to be refined for sonographically identified incidental lesions that may be able to be followed or dismissed. It is important to note that criteria are for nonpalpable lesions at this time. For a lesion to be considered “probably benign,” BI-RADS category 3 [26], it must meet certain criteria:

  • 1.

    The risk of malignancy must be quite small.

Summary

Only practitioners experienced in breast sonography should contemplate offering screening sonography at this time, with full awareness that it is not the standard of care at present [33]. Annual screening mammography beginning at age 40 (or earlier if indicated [34]) remains the only proved test to decrease a woman's chance of dying from breast cancer. A woman with dense or heterogeneously dense breast tissue on mammography contemplating a supplemental screening sonogram in addition to

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  • Cited by (126)

    • Supplemental Cancer Screening for Women With Dense Breasts: Guidance for Health Care Professionals

      2021, Mayo Clinic Proceedings
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      Screening studies have shown a 12% to 15% increase in recall rates with a reported low positive predictive value (9.4%), where false-positive ultrasonography results led to many unnecessary biopsies.83,85 Overall, supplemental screening ultrasonography of women with dense breasts allows detection of more breast cancers at an earlier stage, facilitating less radical treatment options and improved survival rates.48 The ACR91,92 recommends ultrasonography as an optional tool for screening of an asymptomatic woman with dense breast tissue at average to intermediate risk for breast cancer and as a supplemental screening tool for high-risk women who cannot tolerate breast magnetic resonance imaging (MRI).81

    • Automated Breast Ultrasound Interpretation Times: A Reader Performance Study

      2018, Academic Radiology
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      Moreover, breast density is a strong, independent risk factor for the development of breast cancer, with studies demonstrating an increased lifetime risk of 2.8–6.0 times that of women with less dense, fatty breast tissue and a 6.1–17.8 greater risk of interval cancers in women with extremely dense breasts (8–15). Supplemental breast cancer screening with handheld ultrasound has documented an increased detection rate of approximately three to four cancers per thousand women with dense breasts, and, as 85% of cancers detected by screening ultrasound alone are invasive and node negative, ultrasound has become a particularly appealing method of screening (5,16–24). Although ultrasound can help address the challenges of cancer detection in dense breasts, traditional handheld ultrasound has several important limitations, including operator dependency, variable scan quality and reproducibility, and long acquisition times, which raise concerns for broad-scale implementation as an adjunct breast cancer screening tool (25–30).

    • Multimodal ultrasound computer-assisted tomography: An approach to the recognition of breast lesions

      2018, Computerized Medical Imaging and Graphics
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      Supplementing mammography screening tests with conventional ultrasound imaging significantly increases the chances of early cancer detection, especially in the case of dense breast tissue (Berg et al., 2008; Hooley et al., 2012). In this case, however, high sensitivity of ultrasonography (Zonderland et al., 1999; Stavros et al., 1995) is limited due to its low specificity (Berg, 2004; Corsetti et al., 2006). False positive results, in turn, entail a large number of unnecessary biopsies (Saarenmaa et al., 2001; Goddi et al., 2012).

    • Implementation of Whole-Breast Screening Ultrasonography

      2017, Radiologic Clinics of North America
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    Supported by grants from the Avon Foundation and the National Institutes of Health (CA80098).

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