Screening Breast Cancer: the Mammography War

There is an established consensus in the breast health community that mammography is the mainstay imaging examination for screening breast cancer. However, there are varied national recommendations among stakeholders and major institutions in the topic of breast cancer screening. Lack of consensus in screening criteria includes risk stratification, age to initiate screening, and the interval of screening. The differences in practice guidelines are mainly due to variation in design and interpretation of screening trials over the past decades. As debates for and against the use of screening mammography continue to escalate, both providers and patients are often confused and wrongly perceive the recommendations as directives. The purpose of this article is to review the current guidelines, analyze the reason for the controversies in screening mammography, and shine light on the upcoming trends of future screening guidelines.     

Comparison of Mammography in Combination with Breast Ultrasonography Versus Mammography Alone for Breast Cancer Screening in Asymptomatic Women

Aim: To compare the agreement of screening breast mammography plus ultrasound and reviewedmammography alone in asymptomatic women. Materials and Methods: All breast imaging data were obtained forwomen who presented for routine medical checkup at National Cancer Institute (NCI), Thailand from January2010 to June 2013. A radiologist performed masked interpretations of selected mammographic images retrievedfrom the computer imaging database. Previous mammography, ultrasound reports and clinical data were blindedbefore film re-interpretation. Kappa values were calculated to assess the agreement between BIRADS assessmentcategory and BIRADS classification of density obtained from the mammography with ultrasound in imagingdatabase and reviewed mammography alone. Results: Regarding BIRADS assessment category, concordancebetween the two interpretations were good. Observed agreement was 96.1%. There was moderate agreement inwhich the Kappa value was 0.58% (95%CI; 0.45, 0.87). The agreement of BI-RADS classification of density wassubstantial, with a Kappa value of 0.60 (95%CI; 0.54, 0.66). Different results were obtained when a subgroupof patients aged ≥60 years were analyzed. In women in this group, observed agreement was 97.6%. There wasalso substantial agreement in which the Kappa value was 0.74% (95%CI; 0.49, 0.98). Conclusions: The presentstudy revealed that concordance between mammography plus ultrasound and reviewed mammography alonein asymptomatic women is good. However, there is just moderate agreement which can be enhanced if agetargetedbreast imaging is performed. Substantial agreement can be achieved in women aged ≥60. Adjunctivebreast ultrasound is less important in women in this group.     

Improved Detection Rate of Early Breast Cancer in Mass Screening Combined with Mammography

A cohort study to compare mass screening with and without mammography was conducted in Miyagi Prefecture, Japan in order to establish whether the effectiveness of breast cancer screening would be improved when mammography was combined with physical examination. A trial of mass screening combined with mammography was carried out in 9634 women aged over 50. Lateral imaging of the breast using single-view film mammography was performed at the first stage of mass screening in addition to physical examination of the breast. Results in the trial were compared with those obtained in 35511 age-matched subjects without mammography. Thirty breast cancers were found in the trial with a detection rate of 0.31%, which was much higher than that (0.08%) obtained by physical examination without mammography. In 15 of the 30 patients the breast tumor was not palpated at the first screening, but abnormal findings were detected in the mammography. A higher rate (73%) of early breast cancer was obtained in the screening trial with mammography than that (39%) obtained in the screening with physical examination alone. Mass screening combined with mammography is superior to that without mammography for breast cancer screening, especially for the detection of non-palpable, early breast cancer.     

Breast Cancer Screening in Asian Women with Dense Breast by Mammography: A Cross-Sectional Observational Study

Objective: Mammography density of Asian women is known to be higher than Western women. After 2009, the Korean National Cancer Screening Program (NCSP) has started to notify mammography density (MD). To investigate the effect of MD notification, we integrated screening results with national health insurance claim data from 2009 to 2013. Patients and Methods: We performed a cross-sectional observational study which investigated the crude detection rate (CDR), positive predictive value (PPV), and incidence rate of Interval Cancer (IC). IC was defined as breast cancer, where the interval between the screening date and date of diagnosis was more than 12 months and less than 24 months among participants with previous normal results. Results: CDR and PPV per 100,000 results increased from 510.9 to 756.2 and from 1842.5 to 3364.9, respectively. The incidence rate of IC per 100,000 negative results increased from 623.3 to 676.2. Women younger than 50 years had a high incidence of ICs. Conclusion: After notifying MD, the incidence rate of IC less increased comparing with CDR or PPV. Screening mammography could be more useful to Asian women when reporting MD.     

Role of Mammography versus Magnetic Resonance Imaging for Breast Cancer Screening

Mammographic screening has been proven to detect breast cancer at an early stage and to reduce mortality from breast cancer. Nevertheless, some limitations concerning sensitivity, as well as adverse effects such as false negatives and radiosensitivity, has led to a need to search for other screening techniques. Magnetic resonance imaging has been an excellent choice for some specific subgroups, including patients at high risk. However, high cost, low availability, and lack of long-term trials aiming to prove the reduction of mortality have limited magnetic resonance application. Moreover, some points about breast cancer screening still need to be clarified, including overdiagnosis rate, which includes cancers that would not have become clinically significant during the woman’s lifetime, and cost effectiveness. In this review, the authors analyze the role of mammography and magnetic resonance imaging in breast cancer screening for the general and high-risk populations.     

To乳腺癌的X线诊断

目的：总结Ｔｏ乳腺癌Ｘ线特征及与病理的关系。方法;对１２０例次乳腺Ｔｏ癌患者中,有乳腺Ｘ线检查的９７例次病例进行了回顾性分析。结果：Ｔｏ乳腺癌的Ｘ线检查阳性率为３２．９９％,可疑率２１．６５％,合计５４．６４％。Ｔｏ乳腺癌Ｘ线表现以局限致浸润及钙化为主,占Ｘ线阳性表现病例中６６％,以肿块为表现者罕见,仅３例。     

Mammography Surveillance Following Breast Cancer

Background. To describe when women diagnosed with breast cancer return for their first mammography, and to identify factors predictive of women returning for mammographic surveillance. Methods. Women who underwent mammography at facilities participating in the National Cancer Institute's Breast Cancer Surveillance Consortium (BCSC) during 1996 and who were subsequently diagnosed with ductal carcinoma in situ or invasive breast cancer were included in this study. Data from seven mammography registries were linked to population-based cancer and pathology registries. Kaplan–Meier curves were used to depict the number of months from the breast cancer diagnosis to the first mammogram within the defined follow-up period. Demographic, disease and treatment variables were included in univariate and multivariate analyses to identify factors predictive of women returning for mammography. Results. Of the 2503 women diagnosed with breast cancer, 78.1% returned for mammography examination between 7 and 30 months following the diagnosis. Mammography facilities indicated that 66.8% of mammography examinations were classified as screening. Multivariate analyses found that women were most likely to undergo surveillance mammography if they were diagnosed at ages 60–69 with Stage 0, I or II breast cancer and had received radiation therapy in addition to surgery. Conclusions. While the majority of women return for mammographic surveillance following breast cancer, some important subgroups of women at higher risk for recurrence are less likely to return. Research is needed to determine why some women are not undergoing mammography surveillance after a breast cancer diagnosis and whether surveillance increases the chance of detecting tumors with a good prognosis.     

Knowledge,Barriers and Attitudes Towards Breast Cancer Mammography Screening in Jordan

Background: Breast cancer is the most common type of cancer in Jordan. Current efforts are focused onannual campaigns aimed at increasing awareness about breast cancer and encouraging women to conductmammogram screening. In the absence of regular systematic screening for breast cancer in Jordan, there is aneed to evaluate current mammography screening uptake and its predictors, assess women’s knowledge andattitudes towards breast cancer and screening mammograms and to identify barriers to this preventive service.Materials and Methods: This cross-sectional study was conducted in six governorates in Jordan through faceto-face interviews on a random sample of women aged 40 to 69 years. Results: A total of 507 participants withmean age of 46.8±7.8 years were interviewed. There was low participation rate in early detection of breastcancer practices. Breast self-examination, doctor examination and periodic mammography screening werereported by 34.9%, 16.8% and 8.6% of study participants, respectively. Additionally 3.8% underwent breastcancer screening at least once but not periodically, while 87.6% had never undergone mammography screening.Reported reasons for conducting the screening were: perceived benefit (50%); family history of breast cancer(23.1%); perceived severity (21.2%); and advice from friend or family member (5.8%). City residents haveshown higher probability of undergoing mammogram than those who live in towns or villages. Results revealednegative perceptions and limited knowledge of study participants on breast cancer and breast cancer screening.The most commonly reported barriers for women who never underwent screening were: fear of results (63.8%);no support from surrounding environment (59.7); cost of the test (53.4%); and religious belief, i.e. Qadaa WaQadar (51.1%). Conclusions: In the absence of regular systematic screening for breast cancer in Jordan, theuptake of this preventive service is very low. It is essential for the country of Jordan to work on applying regularsystematic mammography screening for breast cancer. Additionally, there is a need for improvement in thecurrent health promotion programmes targeting breast cancer screening. Other areas that could be targeted infuture initiatives in this field include access to screening in rural areas and removal of current barriers.     

Mammography Screening and Breast Cancer Mortality in New South Wales, Australia

OBJECTIVE: To investigate the relationship between utilisation of service mammography screening and breast cancer mortality in New South Wales (NSW) women. Setting : Population-based biennial mammography screening was progressively introduced in NSW from 1988, with active recruitment and re-invitation for women aged 50-69 years, and reached full geographic coverage by 1996. Biennial mammography screening participation has varied widely over time and by municipality. METHODS: Breast cancer mortality by age, period and municipality was obtained from the NSW Central Cancer Registry. Biennial mammography screening rates for the same strata were obtained from the BreastScreen NSW database. Temporal changes in breast cancer mortality for NSW were summarised as annual average declines using Poisson regression. Breast cancer mortality for 1997-2001 was examined in relation to lagged biennial screening rates by municipality, adjusted for age, area socio-economic and geographic indicators, and breast cancer incidence, also using Poisson regression. RESULTS: For the 50-69 year age group, the mean annual breast cancer mortality decline was 0.8% (not significant) for 1988-1994, and 4.4% (p < 0.0001) for 1995-2001. Statistically significant negative associations between breast cancer mortality in 1997-2001 and lagged biennial screening rates were found with the highest significance at a four-year lag for women aged 50-69 years ( p = 0.0003) and also for women aged 50-79 years (p c = 0.0002). From the regression coefficient, a 70% biennial screening rate is associated with 32% lower breast cancer mortality (compared to zero screening). CONCLUSIONS: The effect of population-based mammography screening on breast cancer mortality in NSW inferred using this method is consistent with results of trials and other service studies. This suggests that population-based mammography screening programs can achieve significant reductions in breast cancer mortality with adequate participation.     

Evidence on Synthesized Two-dimensional Mammography Versus Digital Mammography When Using Tomosynthesis (Three-dimensional Mammography) for Population Breast Cancer Screening

One limitation of using digital breast tomosynthesis (3-dimensional [3D] mammography) technology with conventional (2-dimensional [2D]) mammography for breast cancer (BC) screening is the increased radiation dose from dual acquisitions. To resolve this problem, synthesized 2D (s2D) reconstruction images similar to 2D mammography were developed using tomosynthesis acquisitions. The present review summarizes the evidence for s2D versus digital mammography (2D) when using tomosynthesis (3D) for BC screening to address whether using s2D instead of 2D (alongside 3D) will yield similar detection measures. Comparative population screening studies have provided consistent evidence that cancer detection rates do not differ between integrated 2D/3D (range, 5.45-8.5/1000 screens) and s2D/3D (range, 5.03-8.8/1000 screens). Also, although the recall measures were relatively heterogeneous across included studies, little difference was found between the 2 modalities. The mean glandular dose for s2D/3D was 55% to 58% of that for 2D/3D. In the context of BC screening, s2D/3D involves substantially less radiation than 2D/3D and provides similar detection measures. Thus, consideration of transitioning to tomosynthesis screening should aim to use s2D/3D to minimize harm.     

High Detection Rate of Breast Cancer by Mass Screening Using Mammography in Japan

A trial of mass screening for breast cancer using both mammography and physical examination (independently) was carried out in women over 50 years of age in Tokushima Prefecture. Breast cancer was detected in eight of a total of 950 examinees by mammography alone, and no cases of breast cancer were detected by physical examination. The detection rate of breast cancer was 0.84%, which is very much higher than that obtained by conventional mass screening using physical examination alone. The detection rate increased especially in the sixth and seventh decades of life. All eight detected breast cancers were in the early stage. Based on these results, it is recommended to employ mammography in breast cancer screening for asymptomatic women aged over 50 years.     

Population-based Mammography Screening and Breast Cancer Incidence in New South Wales, Australia

Objective To analyse breast cancer incidence trends in New South Wales (NSW), Australia, in relation to population-based mammography screening targeting women aged 50 to 69 years. Methods Trends in age-specific incidence of invasive breast cancers in NSW women aged ≥40 years were examined in relation to mammography screening rates and screening cancer detection rates. Results Incidence of invasive breast cancer in NSW women increased in all age-groups over 1972 to 2002. The incidence trend for women aged 50 to 69 years showed that the steepest rise was associated with increased participation in population-based mammography screening, which was implemented from 1988 and achieved state-wide coverage in 1995. The elevated incidence of invasive cancer significantly exceeded pre-screening levels, and persisted after rates of initial screens declined. This elevated incidence was sustained by the contribution of cancers diagnosed through subsequent screening, and resulted from increased cancer detection rates in subsequent screens. Conclusions The recent increase in invasive breast cancer incidence in NSW is associated with mammography screening, and occurred mostly in the target age-group women. Persistence of higher incidence after 1994 was not explicable by inflation of cancer incidence due to detection of prevalent screen cases, but was associated with a trend of increased cancer detection rates in subsequent screening rounds, probably consequent to quality improvements in mammography screening diagnosis.     

Improved Performance of Adjunctive Ultrasonography After Mammography Screening for Breast Cancer Among Chinese Females

Introduction

Until now, no studies have investigated whether women other than those with dense breasts are suitable for adjunctive ultrasonography after negative mammography, and investigated whether all women with negative mammography are suitable for adjunctive ultrasonography.

Comparison of False Negative Rates among Breast Cancer Screening Modalities with or without Mammography: Miyagi Trial

False negative rates were compared in two screening modalities, physical examination with or without mammography, in an intervention study for women aged over 50 in Miyagi Prefecture. Thirty-five breast cancers were detected in 12,515 subjects who participated in the trial consisting of physical examination and mammography, whereas 44 breast cancers were detected in 50,105 subjects who received physical examination alone, so that the detection rates were 0.28% and 0.09%, respectively. Among 50,061 subjects who received physical examination alone, 8 women were diagnosed as having breast cancer within 12 months after the screening, while only one of 12,480 screenees receiving the combined modality was so diagnosed, implying false negative rates of 15.4% and 2.8%, respectively. When the screening sensitivity in the combined system was analyzed according to each single modality, the false negative rate provided by physical examination with mammography turned out to be 2.8%, significantly lower than that (33.3%) by the physical examination alone. Minimal breast cancers represented 25.7% of all screen-detected cancers in the combined modality, compared with 9.1% in the modality without mammography. The trial thus indicates that physical examination combined with mammography may be an appropriate modality for breast cancer screening in women aged over 50 on the basis of screening sensitivity.     

Successful First Round Results of a Turkish Breast Cancer Screening Program with Mammography in Bahcesehir,Istanbul

Background: The Bahcesehir Breast Cancer Screening Project is the first organized population basedbreast cancer mammographic screening project in Turkey. The objective of this prospective observationalstudy was to demonstrate the feasibility of a screening program in a developing country and to determine theappropriate age (40 or 50 years old) to start with screening in Turkish women. Materials and Methods: BetweenJanuary 2009 to December 2010, a total of 3,758 women aged 40-69 years were recruited in this prospectivestudy. Screening was conducted biannually, and five rounds were planned. After clinical breast examination(CBE), two-view mammograms were obtained. True positivity, false positivity, positive predictive values (PPV)according to ACR, cancer detection rate, minimal cancer detection rate, axillary node positivity and recall ratewere calculated. Breast ultrasound and biopsy were performed in suspicious cases. Results: Breast biopsy wasperformed in 55 patients, and 18 cancers were detected in the first round. The overall cancer detection rate was4.8 per 1,000 women. Most of the screened women (54%) and detected cancers (56%) were in women aged 40-49. Ductal carcinoma in situ (DCIS) and stage I cancer and axillary node positivity rates were 22%, 61%, and16.6%, respectively. The positive predictivity for biopsy was 32.7%, whereas the overall recall rate was 18.4 %.Conclusions: Preliminary results of the study suggest that population based organized screening are feasibleand age of onset of mammographic screening should be 40 years in Turkey.     

Breast Cancer Diagnosis by Mammography in Kazakhstan - Staging Results of Breast Cancer with Double Reading

While mammography has been used for diagnosis of breast cancer in Kazakhstan for a long period,published data are very limited. Recently stress has been placed on increasing the accuracy by double readingof mammograms. Here we provide an overview of breast cancer screening in the different regions of Kazakhstanwith data on the stages of cancers detected. A total 459,816 women aged 50, 52, 54, 56, 58 and 60 years werescreened in 2012 and 379,903 in the first 9 months of 2013. Clear differences in levels of detection were notedbetween urban and rural residents, the latter demonstrating lower rates for both screening and cancer detection.Women aged 50 were more likely to undergo screening than their counterparts aged 60. While there were noclear relationships evident between screening rates and stage or numbers of breast cancers observed, this mightbe due to a number of complicating factors like geographical variation in risk factors as well as ethnicity. Futureanalyses should focus on the efficacy of mammography in Kazakhstan to reduce mortality.     

Diagnostic Value of Contrast-Enhanced Spectral Mammography for Screening Breast Cancer: Systematic Review and Meta-analysis

Background

Contrast-enhanced spectral mammography (CESM) is a new image examination technology that has developed over the past few years. As CESM technology keeps improving, a current meta-analysis review is needed to systematically evaluate the potential diagnostic value of CESM.

Perception of Breast Cancer Screening among Iranian Women without Experience of Mammography: A Qualitative Study

Background: In Iran, there are high rates of breast cancer. It is among the five most common cancers, thefirst among cancers diagnosed, and is the leading cause of cancer deaths among Iranian women. Objectives: Thepurpose of this qualitative study was to explore perception of breast cancer screening among Iranian women whohave never had a mammograph. Materials and Methods: The current study was part of a qualitative researchconducted by means of content analysis method and purposive sampling of 16 women over the age of 30 yearswho had not undergone mammography using individual semi-structured interviews. Interviews were recordedand transcribed verbatim. The data were under continuous consideration and comparative analysis in order toachieve data saturation. Results: After codification of data, three concept categories were achieved including: i)low awareness, ii) worries, and iii) lack of motivation. Conclusions: Although there is a tendency among Iranianwomen to participate in breast cancer screening, there is a powerful cultural belief that breasts are sexual organsthat should not be discussed publicly. Due to the incidence of breast cancer in Iranian women, it is critical thatbreast awareness education be performed by health care experts to explore the concepts of breast cancer andbreast cancer screening.     

Changes in Incidence of in situ and Invasive Breast Cancer by Histology Type following Mammography Screening

Objective: To investigate secular trends and correlates of incidence of breast cancer by histology type following ‍the introduction of population-based mammography screening. Methods: Analysis of age-standardised incidence ‍rates for 1,423 in situ and 16,157 invasive carcinomas recorded on the South Australian population-based cancer ‍registry for the 1985-2004 diagnostic period. Multiple logistic regression was undertaken to compare sociodemographic ‍characteristics by histology. Progression from in situ disease was investigated using the Kaplan-Meier ‍method. Results: The incidence of in situ lesions increased approximately seven-fold over the 20-year period, compared ‍with an increase of about 40% for invasive cancers. The increase for in situ lesions was due to increases for ductal ‍carcinomas, with little change for lobular lesions. By comparison, the percentage increase in incidence for invasive ‍cancer was greater for lobular than ductal cancers. Both for in situ and invasive cancers, percentage increases were ‍greatest for the screening target age range of 50-69 years. One in 14 in situ cases was found to progress to invasive ‍cancer within seven years of diagnosis, but insufficient detail was available to determine whether the invasive cancers ‍were a progression of the in situ lesions or whether they originated separately. These invasive cancers were smaller ‍than generally applying for other invasive cancers of the female breast. Conclusions: The larger secular increases in ‍incidence for in situ than invasive cancers would reflect the dominant role of mammography in the detection of ‍ductal carcinoma in situ. The lack of an increase for lobular in situ lesions may have resulted from their poorer ‍radiological visibility. The greater percentage increase for lobular than ductal invasive lesions may have been due to ‍an increase in imaging sensitivity for these lesions, plus real increases in incidence. The smaller sizes of invasive ‍cancers found in women with a prior in situ diagnosis may have resulted from more intensive medical surveillance, ‍although the possibility of biological differences cannot be discounted.