Screening guidelines and technology tools were up for discussion Sept. 29, when ACR teamed with the Society of Breast Imaging (SBI) to tee up the Oct. 1 start of Breast Cancer Awareness Month.
Barbara Monsees, MD, chair of ACR’s breast imaging commission and a professor of radiology and women’s health at Washington University School of Medicine in St. Louis, began the media call-in by pointing out that the “screening starting at age 40” school of thought—while contested in some circles—has the backing of not only ACR and SBI but also the American Cancer Society and the American Congress of Obstetricians and Gynecologists.
She noted that, since mammography screening became widespread in the U.S. in the mid-1980s, the breast cancer death rate—which had remained unchanged for the previous 50 years—has dropped by more than 30%. “Some say that the drop is due to better treatment over that period of time and, undoubtedly, better treatment has changed the landscape and the prognosis for women,” said Monsees. But studies have shown that there are fewer breast cancer deaths among women who get screened than among those who do not, she added, “despite the fact that the same modern therapies are available and were available to both groups in those studies.”
Finding cancer earlier in women’s lives also improves the quality of life for many, as more women can have less aggressive treatment, fewer women need mastectomies and fewer need chemotherapy, Monsees said.
“Some advocate that the decision regarding when and how often women choose to get a mammogram should be based on risk. We believe this is a bad recommendation,” she said, adding that 75% of all women diagnosed with breast cancer have no family history or other factors that would place them at high risk for the disease.
“To be sure, mammography is not perfect. No medical test is,” Monsees said. “Some women will need to return for additional views to find out they’re okay. Some women will need to get a biopsy to find out they don’t have breast cancer. Also mammography, unfortunately, cannot find all cancers early enough to save all women. But despite those limitations, we know that mammography saves lives.”
Monsees concluded her prepared remarks by stating: “We have a choice. We can wait until there is a universal cure or a better way to screen for breast cancer or a way to prevent breast cancer. Or we can screen now and save thousands of lives while we search for alternatives.”
High hopes tomosynthesis will improve mammography
Debra Monticciolo, MD, immediate past president of SBI and a professor of radiology at Texas A&M University, concured that mammography is the most effective widespread breast cancer screening tool available. She then described three “additional tools” about which she is enthusiastic—breast MRI, breast ultrasound and breast tomosynthesis.
“Breast MRI and breast ultrasound have been shown to be useful for some women, mostly those at highest risk for breast cancer. But neither breast MRI nor breast ultrasound is used for screening without a mammogram,” Monticciolo noted. “These two tests are not used instead of mammography. Studies have shown that screening with either ultrasound or MRI can help to find breast cancers in high-risk women that cannot be seen on a mammogram.”
Of the three tests, breast MRI is the most sensitive, Monticciolo said, noting that it can detect cancers not found even when mammography and ultrasound are combined. “We tend to favor the addition of MRI for screening high-risk women,” she said, “because of its sensitivity and its reasonable recall and biopsy rates.”
Ultrasound screening finds additional cancers not seen on mammography, but it has a higher false positive rate. “Of the biopsies recommended based on ultrasound screening alone, only about 4% are going to be positive,” said Monticciolo. “That’s far lower than for either mammography or MRI, and this has led some breast imagers to favor MRI when additional screening is needed. I would add that the cost of ultrasound for screening or MRI for screening might not be covered by insurance, which can limit their use.”
Monticciolo seemed to have saved a favorite for last when she pointed out that breast tomosynthesis has shown great promise as an advance over routine digital mammography.
“We have seen higher cancer detection rates and fewer patient recalls when tomo is used for screening,” she said. “This is an important advance in breast imaging.”
Further studies are still needed for us to learn which subgroups of women would benefit the most and to assess tomo’s relationship to long-term clinical outcomes, she added. “For this research to occur, the technology must be widely available and widely utilized,” said Monticciolo. “Right now it is not.”
One barrier, she said, is the lack of reimbursement for tomosynthesis, even though it has been shown to improve key screening parameters compared to routine digital mammography.
“Both the American College of Radiology and the Society of Breast Imaging urge the government and private insurers to facilitate access to these examinations by covering their beneficiaries for tomosynthesis,” Monticciolo said. “Only then can women fully benefit from this advance in cancer detection.”
Exercise caution, not dismissal, of breast tomosynthesis data
After the session, Radiology Business asked for comment on a recent editorial in JAMA. Running in the same edition that carried the study showing 3-D tomo significantly increases the detection of breast cancer while also reducing the need for re-exams, the editorial offered what some observers took as a contrarian viewpoint.
“The message to women and their physicians,” the JAMA editorial stated, “has become more complex and confusing.”
“Although it may seem contrarian, I think the overall message is that more research is needed,” Monticciolo replied. “This is clearly the case, as tomosynthesis is relatively new. We agree that more research would be welcome. Pisano and Yaffe [the editorial’s authors] point out some of the limitations of … nonrandomized design, lack of long term follow up [and so on]. This, however, simply means that we should use caution in applying the results, not that the results are not valid.”
“Several additional studies support the idea that the use of tomosynthesis will increase cancer detection,” Monticciolo added. “But more work can and will be done. We look forward to additional information as research is continued.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.