In breast cancer screening mammography has been proven to one of the most effective detection mechanisms available. Today, it is considered the only screening options that reduces mortality. However, while mammography is still the gold standard of breast cancer screening, reports show that there is increasing awareness of subpopulations of women for whom mammography has reduced sensitivity. Furthermore, over the last decade, mammography has created much debate because of observed false positives and excessive biopsies, with increase radiation dose, cost, and patient anxiety.

These challenges have resulted in the development of new technologies, including low-dose mammography, contrast-enhanced mammography (evaluates blood flow in the breast), tomosynthesis (multiple mammography ?slices? through the breast, similar to a CT scan), automated whole breast ultrasound, molecular imaging, and magnetic resonance imaging (MRI). Many of these new technologies may improve detection of breast cancer both in the general population and in high-risk groups, such as women with dense breasts

To understand the benefits for patients,researchers at Moffitt Cancer Center, in Tampa, Florida, one of only 41 National Cancer Institute-designated Comprehensive Cancer Centers, predict that these advancements in breast cancer screening requires a personalized touch based on metrics of cancer risk with selective application of specific screening technologies best suited to the individual’s age, risk, and breast density. They discuss this in the April 4, 2013 issue of The American Journal of Medicine.[1]

Commenting on their study, lead author Jennifer S. Drukteinis, M.D., assistant member in Moffitt?s Department of Diagnostic Imaging noted: ?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.?

Controversy
The writers of the article refer to a controversial disagreement on mammography screening issues. In 2009, the U.S. Preventive Services Task Force, a panel of health care professionals charged with reviewing published research and making health care policy recommendations, issued guidelines that women should get mammograms every two years starting at age 50. [2] They recommended against screening before 50. Their recommendation generated great controversy, even outrage, because of a well-established convention recommending mammography screening beginning at 40 and, for those with a first-degree relative with breast cancer, screening should start a decade before that relative?s age at diagnosis.

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?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,? noted study co-author Blaise P. Mooney, M.D., 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.?

And while mammography is effective, the authors consider it an imperfect screening tool because, they point out, the sensitivity of it is highly variable. 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 annual mammography may still present with cancers found only on physical examination, they observed. Furthermore, some studies suggest that radiation exposure may contribute to an increase in breast cancer incidence in high-risk populations.

Increased sensitivity and specificity
The authors of the article believe that more successful breast cancer screening requires increased sensitivity and specificity while limiting costs and radiation burden. Optimal patient care will require a new screening paradigm with patient-specific strategies tailored to risk based on family history, age, genetic profiles and breast density.

Emerging technologies
?The sensitivity of mammography is inversely proportional to breast density,? Mooney explained. ?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.?

?Decreases in mortality have not been proved with any of these emerging technologies,? 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.?

Perfect cancer screening?
?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,? Drukteinis noted.

The authors conclude that new technologies will be increasingly personalized, integrating 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.?

For more information:
[1] Drukteinis JS, Mooney BP, Flowers CI, Gatenby RA. Beyond Mammography: New Frontiers in Breast Cancer Screening. The American Journal of Medicine – 04 April 2013 (10.1016/j.amjmed.2012.11.025)
[2]Scientific Advisory Board of Patient Advocate Organizations Disagree with Changes to Mammography Guidelines – Onco’Zine – The International Cancer Network, November 20, 2009

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