Future Breast Cancer Screening Will Need Personalized Approach

The review was published in the April 4, 2013, issue of the American Journal of Medicine. “Although mammography remains the gold standard for breast cancer screening, there is increasing awareness that there are subpopulations of women for whom mammography is limited because of its reduced sensitivity based on an individual’s breast density and other factors,” said study lead author Jennifer S. Drukteinis, MD, assistant member in Moffitt Cancer Center’s (Tampa, FL, USA) department of diagnostic imaging.

The investigators cited a controversial dispute on mammography-screening issues: In 2009, the US Preventive Services Task Force, a panel of healthcare specialists who reviewed published research and made healthcare policy recommendations, issued guidelines that women should get mammograms every two years starting at age 50. They advised against screening before 50. Their recommendation created great debate, even outrage, because of a well-established convention recommending screening beginning at 40, and for those with a first-degree relative with breast cancer, screening should begin 10 years before that relative’s age at diagnosis.

“At present, the task force is the only group or consensus panel in the United States recommending breast cancer screenings to begin at age 50,” said study coauthor Blaise P. Mooney, MD, an assistant member in Moffitt’s department of diagnostic imaging. “There is, however, clear evidence that mammography detects early breast cancers in this population. Data suggest that large-scale screening reduces mortality.”


As effective as mammography has been, the authors consider it an imperfect screening tool. The sensitivity of mammography is highly variable, the authors point out. The effectiveness for women with fatty breast tissue is as high as 98% while the effectiveness for women with dense breasts can be as low as 36%. Women who undergo a yearly mammogram may still present with tumors identified only on physical examination, according to the investigators. Moreover, some studies suggest that radiation exposure may contribute to an increase in breast cancer incidence in high-risk populations.

More effective breast cancer screening requires increased sensitivity and specificity while curbing costs and radiation doses, the authors recommended. They also suggested that optimal patient care would require a new screening model with patient-specific strategies customized to risk based on family history, age, genetic profiles, and breast density. “The sensitivity of mammography is inversely proportional to breast density,” explained Dr. Mooney. “Owing to decreased sensitivity in women with dense breast tissue, but with attention to radiation concerns and a high rate of false positives, breast imagers are adapting with new technologies.”

According to the authors, those new technologies include low-dose mammography, contrast-enhanced mammography (assesses blood flow in the breast), automated whole breast ultrasound, molecular imaging, magnetic resonance imaging (MRI), and tomosynthesis, i.e., multiple mammographic slices through the breast, similar to a computed tomography (CT) scan.

“Decreases in mortality have not been proved with any of these emerging technologies,” Dr. Drukteinis said. “Once more, it is unlikely that any of these new technologies will replace mammography. The role of these new technologies is primarily as an adjunct to screening mammography and can be used in a combination tailored to the individual’s risk factors and breast density, with the goal of maximizing sensitivity and specificity. Given the heterogeneity of the human population, a perfect imaging technology for breast cancer screening will likely never be found. In fact, because of this heterogeneity, the very concept of one strategy fits all may be outmoded.”

The investigators concurred that new technologies will be increasingly personalized, incorporating patient specific and age-dependent factors of cancer risk “with selective application of specific screening technologies best suited to the woman’s age, risk, and breast density.”

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