Abbreviations and Acronyms:ACR (American College of Radiology), CEM (contrast-enhanced mammography), DBN (dense breast notification), DBT (digital breast tomosynthesis), HCP (health care professional), MBI (molecular breast imaging), MRI (magnetic resonance imaging), 3D (3-dimensional), WBUS (whole-breast ultrasonography)
- •Supplemental breast cancer screening methods are intended to detect additional breast cancers in women with dense breast tissue and normal mammography results.
- •Breast tissue composition and breast cancer risk differ among persons, making individualized breast cancer screening important.
- •Women with dense breasts should have a thorough discussion with their health care professionals about the risks and benefits of supplemental dense breast screening. Depending on availability and the patient’s preference, supplemental breast cancer screening considerations can include tomosynthesis, whole-breast ultrasonography, molecular breast imaging, and magnetic resonance imaging.
Background of DBN
A first look at the literacy of America's adults in the 21st century.
- Weiss B.D.
Health literacy: a manual for clinicians.
Supplemental Screening Options
|Incremental CDR per 1000||1.2-2.7||1.2-2.7||6.5-6.9||9.7-16.5||13.1-15.5|
|Advantages||No exposure to ionizing radiation|
Reduces interval cancers in dense breasts
|Reduced recall rate|
Coverage by most insurance carriers
|Sestamibi well tolerated|
Alternative for women with MR contraindication
Lower dose models and biopsy capability under development
|Most sensitive test|
No ionizing radiation
Reduced interval cancers
Development of advanced MR techniques underway
|Less costly than MRI|
Less time-consuming than MRI
|Drawbacks||High recall rates|
Low positive predictive value
Large number of images to review
|Sensitivity modest in extremely dense breasts|
Modest increase in cost and time than standard mammography
|4 times more radiation than standard mammography|
40-min image acquisition time
Gadolinium contrast agent required
Cannot be used in morbidly obese patients and those with severe claustrophobia
|Early research and data studies with low number of participants|
IV iodine contrast agent (potential allergy)
Not widely available
Digital Breast Tomosynthesis
- Lee C.H.
- Dershaw D.D.
- Kopans D.
- et al.
Molecular Breast Imaging
Magnetic Resonance Imaging
- Riedl C.C.
- Luft N.
- Bernhart C.
- et al.
Breast Cancer Risk Assessment Calculators
|Characteristic||Risk prediction model|
|BCRAT or Gail|
|Risk assessment information|
- Ozanne E.M.
- Howe R.
- Mallinson D.
- Esserman L.
- Van't Veer L.J.
- Kaplan C.P.
- Ozanne E.M.
- Howe R.
- Mallinson D.
- Esserman L.
- Van't Veer L.J.
- Kaplan C.P.
- Richman I.B.
- Busch S.H.
Case Vignette, Continued
Supplemental Online Material
- https://www.mayoclinicproceedings.org/cms/asset/d20fe272-25c8-4f0c-a232-3931f567e026/mmc1.mp4Loading ...
- Issues in breast cancer screening.Technol Cancer Res Treat. 2005; 4: 5-9
- Breast cancer screening for women ages 50 to 69 years a systematic review of observational evidence.Prev Med. 2011; 53: 108-114
- Comparative effectiveness of digital versus film-screen mammography in community practice in the United States: a cohort study.Ann Intern Med. 2011; 155: 493-502
- Diagnostic performance of digital versus film mammography for breast-cancer screening.N Engl J Med. 2005; 353: 1773-1783
- National performance benchmarks for modern screening digital mammography: update from the Breast Cancer Surveillance Consortium.Radiology. 2017; 283: 49-58
- Breast cancer screening in the era of density notification legislation: summary of 2014 Massachusetts experience and suggestion of an evidence-based management algorithm by multi-disciplinary expert panel.Breast Cancer Res Treat. 2015; 153: 455-464
- Reader variability in breast density estimation from full-field digital mammograms: the effect of image postprocessing on relative and absolute measures.Acad Radiol. 2013; 20: 560-568
- BI-RADS update.Radiol Clin North Am. 2014; 52: 481-487
- A review of supplemental screening ultrasound for breast cancer: certain populations of women with dense breast tissue may benefit.Acad Radiol. 2016; 23: 1604-1609
- Mammographic breast density as a predictor of radiological findings requiring further investigation.Isr Med Assoc J. 2016; 18: 32-35
- Variation in mammographic breast density by time in menstrual cycle among women aged 40-49 years.J Natl Cancer Inst. 1998; 90: 906-910
- Mammographic density and physical assessment of the breast.AJR Am J Roentgenol. 1987; 148: 525-526
- The association of alcohol consumption with mammographic density in a multiethnic urban population.BMC Cancer. 2015; 15: 1094
- Mammographic density and ageing: a collaborative pooled analysis of cross-sectional data from 22 countries worldwide.PLoS Med. 2017; 14: e1002335
- Raised mammographic density: causative mechanisms and biological consequences.Breast Cancer Res. 2016; 18: 45
- Aromatase inhibitor–induced modulation of breast density: clinical and genetic effects.Br J Cancer. 2013; 109: 2331-2339
- Body size across the life course, mammographic density, and risk of breast cancer.Am J Epidemiol. 2011; 174: 909-918
- Mammographic density, response to hormones, and breast cancer risk.J Clin Oncol. 2011; 29: 2985-2992
- Hormones and mammographic breast density.Maturitas. 2004; 49: 67-78
- Intake of dietary carbohydrates in early adulthood and adolescence and breast density among young women.Cancer Causes Control. 2018; 29: 631-642
- Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41.Radiology. 2012; 265: 59-69
- Breast density as a predictor of mammographic detection: comparison of interval- and screen-detected cancers.J Natl Cancer Inst. 2000; 92: 1081-1087
- Automated and clinical breast imaging reporting and data system density measures predict risk for screen-detected and interval cancers: a case-control study.Ann Intern Med. 2018; 168: 757-765
- Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening.Radiology. 2013; 269: 694-700
- Occult cancer in women with dense breasts: detection with screening US—diagnostic yield and tumor characteristics.Radiology. 1998; 207: 191-199
- Role of ultrasonography in detecting mammographically occult breast carcinoma in women with dense breasts.Radiol Med. 2006; 111: 440-448
- Interreader scoring variability in an observer study using dual-modality imaging for breast cancer detection in women with dense breasts.Acad Radiol. 2013; 20: 847-853
- Breast cancer detection using automated whole breast ultrasound and mammography in radiographically dense breasts.Eur Radiol. 2010; 20: 734-742
- Digital breast tomosynthesis: observer performance study.AJR Am J Roentgenol. 2009; 193: 586-591
- Variation in mammographic breast density assessments among radiologists in clinical practice: a multicenter observational study.Ann. Intern. Med. 2016; 165: 457-464
- The impact of breast density reporting laws on women's awareness of density-associated risks and conversations regarding supplemental screening with providers.J Am Coll Radiol. 2019; 16: 139-146
- A review of breast tomosynthesis. Part II. Image reconstruction, processing and analysis, and advanced applications.Med Phys. 2013; 40: 014302
- Diagnostic efficacy of synthesized 2D digital breast tomosynthesis in multi-ethnic Malaysian population.Sci Rep. 2019; 9: 1459
- Physician ordering of screening ultrasound: national rates and association with state-level breast density reporting laws.J Am Coll Radiol. 2020; 17: 15-21
- Reasons for (non)participation in supplemental population-based MRI breast screening for women with extremely dense breasts.Clin Radiol. 2018; 73: 759.e1-759.e9
- The Connecticut experiment: the role of ultrasound in the screening of women with dense breasts.Breast J. 2012; 18: 517-522
- Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer.Radiology. 2004; 233: 830-849
- Patient-reported breast density awareness and knowledge after breast density legislation passage.Acad Radiol. 2019; 26: 726-731
- A first look at the literacy of America's adults in the 21st century.
- Health literacy: a manual for clinicians.
- Breast density notification letters and websites: are they too "dense"?.J Am Coll Radiol. 2019; 16: 717-723
- Content, readability, and understandability of dense breast notifications by state [erratum appears in JAMA. 2016;315(23):2624].JAMA. 2016; 315: 1786-1788
- Abbreviated breast magnetic resonance imaging (MRI): first postcontrast subtracted images and maximum-intensity projection—a novel approach to breast cancer screening with MRI.J Clin Oncol. 2014; 32: 2304-2310
- Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication?.J Gen Intern Med. 2003; 18: 146-152
- A disparity of words: racial differences in oncologist-patient communication about clinical trials.Health Expect. 2015; 18: 1316-1326
- Patient participation in medical consultations: why some patients are more involved than others.Med Care. 2005; 43: 960-969
- Between-race differences in the effects of breast density information and information about new imaging technology on breast-health decision-making.Patient Educ Couns. 2016; 99: 1002-1010
- Supplemental screening sonography in dense breasts.Radiol Clin. North Am. 2004; 42 (vi): 845-851
- Training the ACRIN 6666 Investigators and effects of feedback on breast ultrasound interpretive performance and agreement in BI-RADS ultrasound feature analysis.AJR Am J Roentgenol. 2012; 199: 224-235
- Supplemental breast MR imaging screening of women with average risk of breast cancer.Radiology. 2017; 283: 361-370
- Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer.J Clin Oncol. 2005; 23: 8469-8476
- Feasibility and diagnostic accuracy of point-of-care abdominal sonography by pocket-sized imaging devices, performed by medical residents.J Ultrasound Med. 2017; 36: 1195-1202
- Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program.Radiology. 2013; 267: 47-56
- Accuracy of screening women at familial risk of breast cancer without a known gene mutation: individual patient data meta-analysis.Eur J Cancer. 2017; 85: 31-38
- Characterisation of microcalcification clusters on 2D digital mammography (FFDM) and digital breast tomosynthesis (DBT): does DBT underestimate microcalcification clusters? Results of a multicentre study.Eur Radiol. 2015; 25: 9-14
- Digital breast tomosynthesis (DBT) to characterize MRI-detected additional lesions unidentified at targeted ultrasound in newly diagnosed breast cancer patients.Eur Radiol. 2015; 25: 2673-2681
- Digital mammography versus digital mammography plus tomosynthesis in breast cancer screening: the Oslo Tomosynthesis Screening Trial.Radiology. 2019; 291: 23-30
- Molecular breast imaging for screening in dense breasts: state of the art and future directions.AJR Am J Roentgenol. 2017; 208: 275-283
- Molecular breast imaging in breast cancer screening and problem solving.Radiographics. 2017; 37: 1309-1606
- Contrast-enhanced spectral mammography (CESM) versus breast magnetic resonance imaging (MRI): a retrospective comparison in 66 breast lesions.Diagn Interv Imaging. 2017; 98: 113-123
- Contrast-enhanced mammography (CEM) for detecting residual disease after neoadjuvant chemotherapy: a comparison with breast magnetic resonance imaging (MRI).Biomed Res Int. 2018; 2018: 8531916
- Comparison of comfort between cone beam breast computed tomography and digital mammography.Eur J Radiol. 2019; 120: 108674
- Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk.JAMA. 2012; 307: 1394-1404
- Adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts: interim report of a prospective comparative trial.J Clin Oncol. 2016; 34: 1882-1888
- A prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2).Eur J Cancer. 2018; 104: 39-46
- Breast cancer screening using tomosynthesis in combination with digital mammography.JAMA. 2014; 311: 2499-2507
- Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study.Lancet Oncol. 2013; 14: 583-589
- Breast cancer screening using tomosynthesis and digital mammography in dense and nondense breasts.JAMA. 2016; 315: 1784-1786
- Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening study.Radiology. 2007; 244: 381-388
- Comparison of abbreviated breast MRI vs digital breast tomosynthesis for breast cancer detection among women with dense breasts undergoing screening [erratum appears in JAMA. 2020;323(12):1194].JAMA. 2020; 323: 746-756
- Supplemental MRI screening for women with extremely dense breast tissue.N Engl J Med. 2019; 381: 2091-2102
- Comparison of screening CEDM and MRI for women at increased risk for breast cancer: a pilot study.Eur J Radiol. 2017; 97: 37-43
- Performance of dual-energy contrast-enhanced digital mammography for screening women at increased risk of breast cancer.Radiology. 2019; 293: 81-88
- Contrast-enhanced spectral mammography in women with intermediate breast cancer risk and dense breasts.AJR Am J Roentgenol. 2018; 211: W267-W274
- Screening breast ultrasound using handheld or automatic technique in women with dense breasts.J Breast Imaging. 2019; 1: 283-296
- Digital tomosynthesis in breast imaging.Radiology. 1997; 205: 399-406
- Dense breasts: a review of reporting legislation and available supplemental screening options.AJR Am J Roentgenol. 2014; 203: 449-456
- Prospective trial comparing full-field digital mammography (FFDM) versus combined FFDM and tomosynthesis in a population-based screening programme using independent double reading with arbitration.Eur Radiol. 2013; 23: 2061-2071
- Performance of one-view breast tomosynthesis as a stand-alone breast cancer screening modality: results from the Malmö Breast Tomosynthesis Screening Trial, a population-based study.Eur Radiol. 2016; 26: 184-190
- Breast cancer screening with tomosynthesis and digital mammography—reply.JAMA. 2014; 312: 1695-1696
- Screening ultrasound as an adjunct to mammography in women with mammographically dense breasts.Am J Obstet Gynecol. 2015; 212: 9-17
- Testing a dual-modality system that combines full-field digital mammography and automated breast ultrasound.Clin Imaging. 2016; 40: 498-505
- Supplemental screening for breast cancer in women with dense breasts: a systematic review for the U.S. Preventive Services Task Force.Ann Intern Med. 2016; 164: 268-278
- Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer [erratum appears in JAMA. 2010;303(15):1482].JAMA. 2008; 299: 2151-2163
- Update on screening breast ultrasonography.Radiol Clin North Am. 2014; 52: 527-537
- Technologist-performed handheld screening breast US imaging: how is it performed and what are the outcomes to date?.Radiology. 2014; 272: 12-27
- Automated whole-breast ultrasound: advancing the performance of breast cancer screening.Semin Ultrasound CT MR. 2011; 32: 273-280
- Benefits, harms, and cost-effectiveness of supplemental ultrasonography screening for women with dense breasts.Ann Intern Med. 2015; 162: 157-166
- Breast cancer detection using sonography in women with mammographically dense breasts.BMC Med Imaging. 2014; 14: 41
- Sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the Japan Strategic Anti-cancer Randomized Trial (J-START): a randomised controlled trial.Lancet. 2016; 387: 341-348
- Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer.J Am Coll Radiol. 2010; 7: 18-27
- ACR Appropriateness Criteria Breast Cancer Screening.J Am Coll Radiol. 2013; 10: 11-14
- Nuclear imaging of the breast: translating achievements in instrumentation into clinical use.Med Phys. 2013; 40: 050901
- Journal club: molecular breast imaging at reduced radiation dose for supplemental screening in mammographically dense breasts.AJR Am J Roentgenol. 2015; 204: 241-251
- Diagnostic workup and costs of a single supplemental molecular breast imaging screen of mammographically dense breasts.AJR Am J Roentgenol. 2015; 204: 1345-1353
- Digital breast tomosynthesis (3D-mammography) screening: data and implications for population screening.Expert Rev Med Devices. 2015; 12: 377-379
- American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography [erratum appears in CA Cancer J Clin. 2007;57(3):185].CA Cancer J Clin. 2007; 57: 75-89
- Alternative screening for women with dense breasts: breast-specific gamma imaging (molecular breast imaging).AJR Am J Roentgenol. 2015; 204: 252-256
- Let's get real about molecular breast imaging and radiation risk (commentary).Radiol Imaging Cancer. 2019; 1: e190070
- Dose reduction in molecular breast imaging with a new image-processing algorithm [erratum appears in AJR Am J Roentgenol. 2019;213(6):1403].AJR Am J Roentgenol. 2020; 214: 185-193
- Comparison of breast MR imaging with molecular breast imaging in breast cancer screening, diagnosis, staging, and treatment response evaluation.Magn Reson Imaging Clin N Am. 2018; 26: 273-280
- Molecular breast imaging–guided percutaneous biopsy of breast lesions: a new frontier on breast intervention.J Breast Imaging. 2020; 2: 484-491
- Which risk model to use? Clinical implications of the ACS MRI screening guidelines.Cancer Epidemiol Biomarkers Prev. 2013; 22: 146-149
- Genetic heterogeneity and penetrance analysis of the BRCA1 and BRCA2 genes in breast cancer families. The Breast Cancer Linkage Consortium.Am J Hum Genet. 1998; 62: 676-689